Mindfulness Course Joining Questionaire
Sign in to Google to save your progress. Learn more
Contact Information
Name *
Address *
Date of Birth *
Telephone Number *
Require for any last minute information we may need to convey to you.
Email Address *
Health Care Information
To help us guide you most effectively on the course, it would be very helpful if you would answer the following questions where appropriate. The information you give is strictly confidential.
If you have any physical illness or other limitation that may make sitting, standing, walking or doing simple exercises difficult for you, please tell us about it here.
If you have had any mental ill-health within the last few years, such as anxiety or depression, please tell us about it here.
If you are taking any medication at present, please say what it is and what it is for.
Name, address and phone number of GP or other health professional
I understand that this mindfulness course is taught for educational purposes only. If I am suffering from a medical condition, I have checked with my doctor/health professional that this course is suitable for me *
Signature *
By way of signature please enter your full name
Today's date *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy