Medical Form

We collect this information to help our practitioners prepare for your retreat experience and individual treatment. This information is only shared with qualifying practitioners for the date of the event. It remains internal unless we are required to share it with first aiders or emergency services.

Name *

First

Last
Age Group *

60+ 50-59 40-59
30-39 Under 30
E-Mail *
Phone Number *
Address *

Address Line 1 *

Address Line 2

City *

County *

Post Code *

Who is your Emergency Contact? *

Emergency Contact Phone *

Are you taking any Medication? *

Yes No

Please list your medications.

Please include a full list of allergins and your medications (epipen, tablets).

Do you have any Allergies? *

Yes No

What are you allergic to? Include everything.

Please include a full list of allergins and your medications (epipen, tablets).

Do you have Heart or Blood Pressure conditions? *

Yes No

Please describe your condition(s).

Please include a full list of allergins and your medications (epipen, tablets).

Do you have Respiratory Conditions or Asthma? *

Yes No

Do you have Diabetes or Hypoglycemia? *

Yes No

Do you have Epilepsy or experience frequent or occasional seizures? *

I have Epilepsy I don’t have Epilepsy, but I experience frequent or occasional seizures No

How frequently do you have seizures? When was the last time you had a seizure?

Do you have a Motor Neuron Disease or any other neurological disorder? *

I have Motor Neuron Disease I have another Motor Neuron Disorder No

Please describe your condition and inform us of anything we need to know to support you.

Do you have Arthritis or frequently experience stiff joints? *

Yes No

Do you have any mobility issues (including musculoskeletal injuries, etc)? *

Yes No

Please briefly explain your mobility issues?

Are you currently in pain? *

Yes No

Describe your pain, where it is, and when you most feel it?

What questions do you have about your kinesiology treatment?

What else about your health and wellbeing do you think is important to share with us?

Please let us know if you are under any treatment for cancer, cardiovascular disease or anything else you think may be relevant.