Mindfulness Course Joining Questionaire
Contact Information
Name
Your answer
Address
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Date of Birth
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Telephone Number
Require for any last minute information we may need to convey to you.
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Email Address
Your answer
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.
Your answer
If you have had any mental ill-health within the last few years, such as anxiety or depression, please tell us about it here.
Your answer
If you are taking any medication at present, please say what it is and what it is for.
Your answer
Name, address and phone number of GP or other health professional
Your answer
Declaration
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
Required
Signature
By way of signature please enter your full name
Your answer
Today's date
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