Yuangong Student form
BACKGROUND HEALTH AND YOUR GOALS
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Email address
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Your email
Are you registering for
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Online Class Tuesday Afternoon - Xia Yuan
Online Class Tuesday Evening - general Practice
Online Class Thursday Morning - 5th/6th Methods
Individual session
Name
Your answer
Address
Your answer
Email
Your answer
Phone
Your answer
D.O.B
Your answer
Occupation
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Dr & or other Practioner
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Present use of Medication/Herbs/Supplements
Your answer
Any Allergies
Your answer
Any Present health conditions?
Your answer
Past History (illnesses, accidents, operations)?
Your answer
What would you like to get out of Yuangong?
Your answer
Areas of your life that you would like to see significant change
Your answer
What other modalities have you tried and/or are you currently practicing?
Your answer
Any other information you think is important to know about yourself?
Your answer
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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