Ananda Institute of Alternative Living
Medical Questionnaire
Print out this form, fill out and mail to:
Send to:
Nakula Cryer
nakula@meditationretreat.org
Ananda Institute of Alternative Living
Ashram Program
14618 Tyler Foote Road, #114
Nevada City, CA 95959 USA
Today’s Date: Day__________Month__________________Year_________
The Ananda Institute of Alternative Living Ashram Program requires that you participate in a variety of activities-some more strenuous than others. To help us decide if this program is right for you, please answer the questions below. All responses are confidential.
Name______________________________________Birth Date__________________
1.Please briefly describe you current overall health.
2.Any back trouble now or in the past? (Y) (N) If yes, please describe.
3.Any trouble with joints (knees, shoulders, ankles, etc.) (Y) (N) If yes, please describe.
4. Blood pressure (circle one): High / Low / Normal When was it last checked?
5. Have you ever taken blood pressure medication? (Y) (N) If so, how recently?
6. Is your heart healthy? (Y) (N) Any history of heart attack? (Y) (N) If yes,
please explain.
7. Circle any of the following difficulties you have had:
Chronic headaches / Ulcers / Stroke / Diabetes / Allergies
Other:_________________________________________________________________
Please explain in detail if any circled above.
(Our kitchen cannot accommodate all dietary restrictions.)
8. Women: Are you pregnant? (Y) (N)
9. Do you have any other physical limitations or health concerns? If so, please explain
10. Are you now taking medication for any physical or psychological conditions? (Y) (N)
If yes, what conditions, what medications, and taken how often?
11. Do you have a history of psychological problems: depression, bipolar disorder, or other? If Yes, please explain.
Whom may we contact in case of an emergency?
Name__________________________________________Relationship_________
Address____________________________________________________________
Phone______________________________________email____________________
I hereby certify that the above information is correct to the best of my knowledge:
NAME (please print)________________________________
PARTICIPANT’S SIGNATURE___________________________________
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