First Name*
Last Name*
Email*
Phone Number*
Date and Location of the workshop you are participating in*
Are you currently pregnant?* YesNo
Have you recently undergone surgery?* YesNo
Are you on any kind of medication?* YesNo
If so, please state below.
Are you currently undergoing psychotherapy?* YesNo
Have you ever been diagnosed with a psychiatric condition?* YesNo
Have you ever been hospitalized for a psychiatric condition?* YesNo
Do you have a past or current history of cardiovascular disease?* YesNo
Do you suffer from hypertension/elevated blood pressure?* YesNo
Are you a diabetic?* YesNo
Would you consider yourself addicted to any substance other than nicotine or caffeine? (We will be in contact to clarify further implications if the answer is yes.) This is not in itself a criterion for exclusion.* YesNo
Have you got any relevant current or past physical injuries, such as osteoporosis, fractures, dislocations or back injuries?* YesNo
If yes, please shortly describe a) what kind of injury and b) when it happened:
Do you suffer from any relevant physical condition, such as hernias that will require surgical care in the near future?* YesNo
Do you suffer from any transmittable/infectious diseases?* YesNo
Are you affected by any ocular condition, such as glaucoma or retinopathy?* YesNo
Do you suffer from asthma, COPD or emphysema?* YesNo
Do you have a current or past history of neurological conditions, such as strokes, epileptic seizures or strokes?* YesNo
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