Women Wellness Retreat _ Autumn Balance 19th September 2025 , The Grange Autumn Balance Retreat 2025 , Health Questionnaire Your DetailsName(Required) First Last Email(Required) Enter Email Confirm Email Phone Number(Required)Date of Birth(Required) Day Month Year Emergency Contact DetailsEmergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Your ExperienceHave you practiced yoga before?(Required) No, never Yes, but some time ago Yes, but only Occasionally Yes, frequently Please give details about your experience with yoga (e.g. years practicing, type of yoga and frequency)(Required)Your Medical HistoryDo any of these health conditions apply to you? High blood pressure Low blood pressure / fainting Arthritis Diabetes Epilepsy Heart problems Asthma Depression Anxiety Detached retina /other eye problems Recent fractures /sprains Recent operations Back problems Knee problems Neck problems Hip problems Carpal Tunnel Syndrome Sciatica Recent pregnancy (how many months postnatal?) Currently pregnant (how many weeks?) Currently undergoing fertility treatment Other conditions (please state below) Please give details about the conditions above (if applicable)Please give details of any allergies that you have (if applicable)Please read and confirm(Required) I confirm that, to the best of my knowledge, these responses are truthful and that I am not aware of any reason why I should not attend a yoga retreat. I acknowledge that all physical exercises carry a risk of harm and agree to assume full responsibility for my health and well-being, including any injuries that may occur during yoga courses. I will inform Julia of any changes to my health. Newsletter(Required) Subscribe to the Julia K Healthy Living newsletter Δ Start your health journey Schedule Your 20 Minute Consultation
