Body Treaments and Yoga

Pre Class Health Questionnaire

All information is Strictly Confidential and will be kept securely. Please complete all the questions on this form and press SUBMIT.

Your Name (required)

Your Email (required)

Address (required)

Address 1

Address 2

Post Code (required)

Your Telephone Work

Your Telephone Mobile

Your Telephone Home

Age Group (required)
 Under 16 17-34 35-44 45-64 65+

Have you practiced Yoga before?

If yes, what type(s) and for how long?

What is your main reason for wanting to do Yoga? (required)

Which aspects of Yoga most interest you? Please tick as many as you wish (required)
 Physical postures (asanas) Relaxation Chanting & Healing Breathwork (pranayama) Meditation Ashtanga
Other aspects (please say which):

Do any of these health conditions apply to you? If yes, please give details

High blood pressure

Low blood pressure/fainting

Arthritis

Diabetes

Epilepsy

Heart Problems

Asthma

Depression

Detached retina/other eye problems

Recent fractures/sprains

Recent Operations

Back problems

Knee problems

Neck problems

Recent pregnancies

Are you pregnant?

Do you have any other conditions which affect your mobility or are likely to cause you concern when doing Yoga? (required)
 Yes No

If Yes, please give details:

How did you first hear about this class? (required)

Please complete the security question below (required)
3x3=? 

I take full responsibility for my health during the yoga classes, including any injuries.
I will inform my Yoga teacher of any medical changes. (required)

Acceptance

Thank you very much for completing this form. I declare to the best of my knowledge that the information given above is correct. Pressing SUBMIT constitutes an electronic signature