Health Questionnaire

Personal Details

Emergency Contact Details

Questionnaire

Have you attended a yoga class before?

The following information is required to ensure your safety. Whilst yoga may be practised safely by most people, there are certain conditions which require special attention. If you are unsure, please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions.Abdominal disorder or recent surgeryUnspecified back pain/ problemsJoint replacementhip problemsheart disorderslow blood pressureArthritis (osteo or rheumatoid)Spinal injuryknee problemsshoulder or neck problemshigh blood pressureOtherNone of the above

These conditions may affect your practice and so provide useful information for your tutor.AsthmaAnxiety/depressionEpilepsyRespiratory issuesSensory disorder affecting eyes or earsDiabetesAuto-immune disorder (e.g. M.E. M.S. Lupus etc.)Balance affecting disorderMigraineOther (discuss with tutor)None of the above

Please tick this box if you do not wish to declare medical informationTick box

DECLARATION I accept the terms of service below

I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class. I also understand that it is my responsibility to:
• check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class
• advise the yoga tutor of any change in my medical information or ability to participate in the yoga class
• follow the advice given by my doctor and/or yoga tutor

In order to comply with the General Data Protection Regulations, it is necessary to check whether, or not, you are happy for me to retain your contact details, and to email you information I think will be useful to you, including training and events, and relevant updates. I only hold information when it is necessary for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, can you please indicate below your preference(s) or otherwise, when contacting you. Please note that you are able to amend these choices at any time by contacting your tutor.
PostEmailMobile phone(text/SMS)None of the above