Health Assessment Form - for zoom sessions
Yoga with Karen Buckland...all information is confidential
You are welcome to join your first zoom session for free
Full Name
*
Please include your first name, then your surname
Email
*
example@example.com
Your age
*
Previous Yoga experience
*
Never before
Some experience
Much experience
Not applicable
Previous Meditation experience
*
Never before
Some experience
Much experience
Not applicable
Are you currently pregnant?
*
Yes
No
Do you experience any of the following?
*
High Blood Pressure
Low Blood Pressure
Heart Condition
Glaucoma
Hernia
Back Pain
Asthma
Anxiety
Depression
Current Injury
Limited mobility from a past injury
Recent surgery
Pregnancy related issue
Side effect of medication
OTHER (please write below)
NONE
If you ticked ANY item of the previous question, please provide more details of your condition:
If there is something you may be sensitive to, please note it here. Otherwise leave 'blank'.
What would you like to gain from Yoga or Reiki or meditation practice?
eg. helping with anxiety, to breathe better, meditation, mindfulness, etc
Is there any other information you wish to share?
Which zoom session would you like to attend for your first freebie? (please choose one)
Mon 10am Yoga (AEST)
Mon 8pm Yoga Nidra (AEST)
Tues 8pm Yoga (AEST)
Fri 10am Yoga & Yoga Nidra (AEST)
After you have submitted this form, you will receive an email from me with the zoom link and some helpful info. Please allow a day to receive a reply. I look forward to welcoming you to our friendly online community! ~ Karen
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