Living Discipleship Medical Form Step 1 of 6 16% Please fill out this questionnaire completely and honestly. The information you provide will be respected and is considered confidential. It will be shared with medical personnel in case of emergency, accident or illness, as required. Information that relates to your ability to practice yoga postures safely (high blood pressure, structural issues, or others) will be shared with yoga postures instructors to help them guide you appropriately. Your answers will help us to work with you as a multi-dimensional individual. Your well-being throughout the program is our highest priority. Name* First Last Email* Current Age* BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Physical Health HistoryPlease briefly describe your current overall health.*Do you have any serious allergies (environment, propane, bees, medications, foods, nuts) that might cause you to stop breathing, or have an asthma attack or seizure?* Yes No Please describe your allergies and symptoms*Do you carry antidotal medication with you at all times?* Please select the conditions below that you have experienced:*Select the "Ctrl" button on your keyboard to select multiple items.NoneAcid RefluxAddictionAneurysmAsthmaArthritisAuto-Immune DisorderBlood-Born DiseaseBlood Pressure IssuesBroken BonesCancerDiabetesHeart AttackHeart or Vascular DiseaseHypo or Hyper ThyroidInflammationInstability - including the spine, back and neckIrregular HeartbeatJoint PainMigraines or HeadachesNeurological IssuesSeizuresSleep Issues or DisordersStrokeSurgeryTachycardiaTorn or Injured Muscles, Ligaments or TendonsVertigoOTHER (please indicate below)Please describe your symptoms:*If you selected any conditions above, please explain if these conditions are in the past, present, and if they continue to impact you in any way, including your ability to get around, walk a distance, exercise, sit, breathe, restrict your diet, etc.*Do you experience pain whether it’s chronic or triggered by something, and whether or not you have a diagnosis that explains the pain. Please describe:*Are you currently under the advice of a physician or other health practitioner for any physical conditions listed above, or others? If yes, please list the conditions:*When was your blood pressure last checked?* Please indicate your blood pressure:* High Normal Low If high or low, how does it affect you?*Please list any medications you are taking for the above or any conditions or issues, including dosage strength and how often you are taking it. Please note, this information would only be used in case of emergency or if you were not able to speak for yourself.*Are you experiencing any symptoms that you are not seeking medical help for? This may include: any kind of intermittent or constant pain, shortness of breath, headaches, dizziness, nausea, chest pain/discomfort, joint or spinal pain, insomnia, memory loss, etc. Please describe:*Women: Are you pregnant? If yes, how many weeks/months? Neurological or Mental Health HistoryIn the past ten years up to the present: Have you been under the care of a physician or other health care practitioner for any neurological conditions, psychological or mental health issues?* Yes No Is the condition still active?* Yes No What do you experience? How does it affect your daily life?*What was or is the condition, and how were or are you being treated for it? (example: depression, anxiety, PTSD, bipolar disorder, schizophrenia, seizures, head injury, aneurysm, stroke, losing consciousness, or other?)*Are you taking any medications prescribed for any physical or mental health conditions? If so, please list the condition, name of medication, dosage, and how often you take it.*If you have been advised to take medication, but are not taking it, please explain why not.*Have you had an emotionally traumatic or stressful experience in the past five years that you feel is still affecting you, such as the loss or illness of someone close, legal proceedings, divorce, family trauma or disharmony, witnessed something very distressing, a severe illness, military service, a long period of stress, loss of job/home/pet/friend, etc? If so, how is it affecting you now?* Health Insurance You are asked to have health insurance when you enter the program, and the program director must have a copy of your health insurance card for the duration of the program. This is kept for emergencies, along with this questionnaire, and will be shredded/deleted upon completion of the program. If you will not have regular health insurance by the time of the program, you may purchase this economical health/travelers insurance for the duration of the program: TravelInsurance.comDo you currently have health insurance?* Yes No Please scan and upload a copy of your health insurance card* Drop files here or Select files Max. file size: 1 MB. Do you expect to have health insurance by the time of the program?* Yes No Acknowledgement of Health Insurance Policy* I take responsibility for having health insurance for the full program duration, and otherwise take full responsibility for financially supporting myself should an emergency occur. Emergency ContactContact Name* First Last Contact Relationship* Contact Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Primary Phone*Contact Secondary Phone*Contact Email* Authorization & ConsentConsent - I hereby certify that this information is correct and may be used in the event of a medical situation or emergency* Please type your full legal name to act as a signature certification*
