Health Questionnaire for Littleway Healing of Memories Course Participants
Dear Participant, could you please complete this form so we can assess any extra support that you may need whilst on the course.

Title
First name:
Last name:
Your email address:

Course location:
Course date:

Please provide details of any mobility restrictions:
Please provide details of any special dietary requirements:
Please provide details of any medical conditions:
Please provide details of any mental health conditions:

Thank you for completing this form!
Date form completed: