Wellness Questionnaire

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Please give us the details of who we should contact in the unlikely event of an emergency
The following will be reviewed carefully to better assist your needs during the program. If you answer yes to any of the following questions, please briefly substantiate your responses below.
Do you have any health conditions or injuries, past or present, which may cause you difficulty, pain or injury?
Please give us more details.
Have you had any surgery in the last 12 months?
Please give us more details.
Are you currently pregnant or trying to become pregnant?
Please tell us how many weeks/ months you will be at the start of the retreat.
Do you have heart condition(s)?
Do you have a history of psychological or emotional illnesses, or issues?
Are you currently taking medication for any physical or psychological condition?
Do you have a contagious disease?
If there is anything else about your state of health that you feel might affect your participation in the program, please explain...
Please specify and indicate the level of intolerance or allergy or dietary requirement.
Do you have any health conditions or injuries, past or present, which may cause you difficulty, pain or injury?
What is your primary diet?
Other Restrictions
Special Needs
In consideration for my participation in the fitness activities at Zen Rocks Mani, I legally bind myself and my heirs, executors and administrators, and hereby wave, fully and finally any causes of action or claims against Zen Rocks along with its owners, directors, officers, employees, members, shareholders, representatives, agents and assignees from any damage of any nature whatsoever, including, but not limited to any personal injuries incurred by the undersigned patron, user/subscriber/member of the Zen Rocks, directly or indirectly resulting from participating in the services and/or activities undertaken at Zen Rocks, as well as any personal injury sustained by the undersigned patron’ s presence on the real property of Zen Rocks Whether or not participating in or utilizing the services and/or activities of Zen Rocks.

I understand that from time to time during classes at Zen Rocks, instructors may physically adjust students’ form when making yoga postures. If I do not want such physical adjustments, I will inform the instructor at each class or session I attend. I also acknowledge that if I do not wish to receive such adjustments, it is my responsibility to inform the instructor when an adjustment has gone as far as I desire at that time. I acknowledge that it is my responsibility to ascertain that there is no medical reason to prevent my participation at Zen Rocks activities. I have read and understand the above policies.
I accept the Release Weaver as stated above:
Thank you! Your submission has been received!
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In case of emergency:

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