New Client Yoga & Movement form

New Client Yoga & Movement form
Please complete this form thoroughly and hand back to your Yoga tutor before starting your Yoga session (or for corporate events: to the wellbeing lead in your company)

For any queries please contact:

Sherene@circularflow.co.uk
This form is for
NAME
PHONE NUMBER

Area CodePhone Number
E MAIL
example@example.com
Date of birth

DayMonthYear
Date
EMERGENCY CONTACT NAME
RELATIONSHIP
PHONE NUMBER

Area CodePhone Number
Circular Flow occasionally sends information or special offers about the following activities, please circle if you would like to be included in the mail out your information will not be used or sent to any third party organisations.

Breath workBodywork, Massage, Myofascial ReleaseYoga & MovementHypnotherapyWomens Health
Multiple sclerosis Yes / No How long have you had it?
Diabetes, type 1 or 2, Do you take Insulin?
Do you have cancer and if so: what type of cancer, year of diagnosis, surgeries & past & current treatment
Do you have high/low blood pressure? If so, please list your medication.
Have you had spinal injury, surgery, or fusion Yes / No Cervical, Thoracic, Lumbar? Please explain:
Do you have Sinus problems Yes / No Do you regularly take sinus medication?
Do you have carpel tunnel or RSI, if so, have had surgery or any medication for it?
Do you have any knee injury Yes/No and if so which side Left/Right. Can you put weight on your knees?
Do you have any chronic problems or reoccurring pain? What and where is it?
If your doctor has given you instructions or contraindicated exercises and movements to avoid, please explain.
Are you currently under a doctor's care? If yes, please list the name and phone number of the doctor.
Dr Surgery/ name of Dr
Dr Surgery number

Area CodePhone Number
Do you have ANY condition that would require a doctor's approval to participate in practicing Yoga? If yes, please explain and inform the teacher as you will need a doctor's consent form.
Do you regularly take any additional medication(s), vitamins, or supplements that would affect your participation in Yoga? If yes, please list all.
What would you like to gain/receive from your Yoga practice? Ie: for mental health, physical well-being, for flexibility, for strength, doing a specific yoga posture, to learn more about a specific element of Yoga etc...
Online classes: For your safety and for insurance purposes please have your device camera on whilst participating in class, that way the teacher can see you are practicing safely, be able to help with your alignment and to see if you have any queries.

Yoga is for everyone. However, when online, it is up to the individual to assess whether they are ready for the class that they have

The practice of yoga asanas requires you - the practitioner - to gauge the safety of your practice within your personal physical limitations. Circular Flow Itd/ Sherene Banner assumes no responsibility for injuries suffered while practicing these techniques and you have completed the form as fully and accurately as you can.
Payment- can be done by bank transfer or paypal

Paypal: @circularflow (mark as friend/ trusted payee to avoid fees) / Please email sherene@circularflow.co.uk for bank details
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New Client Yoga & Movement form

Payment- can be done by bank transfer or paypal