General Health Questionnaire

So we can provide the best learning experience for you guys we just need to collect a few more bits of information from you

It helps us to know a bit about your physical and mental wellbeing for example:

• is there anything you might find physically challenging to do?
• is there any activity that might bring up past trauma or mean you need more time to process?
• your physical address and phone number so we can send you your certificate when you qualify! 

Please fill out the form below so we can update your information, we respect you so this information is 100% confidential. It is important you use the same email address we already have for you.

Please answer the following questions fully and honestly

Name:

Email:

Date of Birth:

Day1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MonthJanuary February March April May June July August September October November December Year2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922

Phone Number:

Address:

Please tell us about any current phsyical limitations you have

Please tell us about any old injuries you have that we may need to be aware of

Do you have any medical conditions?

Have you experienced anxiety or depression in the last 2 years?

Do you have any significant stress affecting you on a day to day basis and if so, how does it affect you?

Please tell us about any other mental or physical issues you would like us to be aware of

And finally, let us know if you have any problems with the written language; e.g. dyslexia or English as a second language

We respect your email privacy

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Thank you!