Skip to content
Login
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Main presenting problem/issue, if any
Your Health
Please indicate if any of the following apply to you
High blood pressure
Low blood pressure
Recent operation or hospital admission
Arthritis
Epilepsy
Pain
Back problems
Chronic illness
Weight issues
Migraine
Dizzy spells
Depression
Chronic fatigue
Fibromyalgia
Health Details
(Required)
Please give details about the condition(s) you selected above
Your Experience
(Required)
Have you practiced mindfulness or yoga before?
Yes
No
Expectations
What are you hoping to gain by attending the classes?
Other difficulties
Have you suffered from any significant trauma or difficulties that would be helpful for the teacher to know about? Please give details.
Hearing/Sight
(Required)
Are you hard of hearing or do you have difficulties seeing the screen?
Yes
No
Other details
Is there anything else you would like to add?
Please call me on 01823 697890 or email info@mindfulnessuk.com, in confidence, if there is anything additional that you feel it would be important for me to know to enable me to support you as best I can during the classes. All the information given will be stored securely and adheres to GDPR.
Declaration
(Required)
I declare that I have disclosed all the relevant information regarding my health and well- being.
I have disclosed all relevant information
Book Now