Yuangong Student form
BACKGROUND HEALTH AND YOUR GOALS
Email address *
Are you registering for *
Name
Address
Email
Phone
D.O.B
Occupation
Dr & or other Practioner
Present use of Medication/Herbs/Supplements
Any Allergies
Any Present health conditions?
Past History (illnesses, accidents, operations)?
What would you like to get out of Yuangong?
Areas of your life that you would like to see significant change
What other modalities have you tried and/or are you currently practicing?
Any other information you think is important to know about yourself?
This form remains completely confidential and any detail is filled out voluntarily. If this form is submitted via google docs on a public domain please share information in a way that you feel comfortable alternatively you can print this form, scan and email privately. All information is used to increase the effectiveness and safety of the teachers delivery of classes, workshops, retreats or individual sessions you may be attending.
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