General Yoga: Health Questionnaire for New Students
Please note that by submitting your information, you are agreeing to receive marketing and email communication from Tania Poole Wellness. All information is strictly confidential and handled in compliance with GDPR.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Format: 00000000000.
What is your age group?
*
Please Select
Under 25
25-35
36-45
46-55
56-65
65+
Have you done yoga before?
*
Yes
No
If 'yes', what type(s) and for how long?
What is your main reason for wanting to do yoga?
*
Which areas of yoga most interest you? (please tick any that apply)
*
Physical postures (asanas)
Relaxation
Chanting and healing
Breathwork (pranayama)
Meditation
Ashtanga
Unsure
Other
Do any of these health conditions apply to you? (please tick any that apply)
*
High blood pressure
Asthma
Low blood pressure / fainting
Diabetes
Arthritis
Heart problems
Epilepsy
Depression
Back problems
Recent fractures/sprains
Recent operations
Knee problems
Neck problems
Recent pregnancies
Are you pregnant?
None of the above
Detached retina / other eye problems
Other
If you have selected any of the above, please provide further information below:
*
Do you have any other conditions which affect your mobility or are likely to cause you concern when doing Yoga?
*
Yes
No
If 'yes' please provide more information:
*
Where did you first hear about this class?
*
I take full responsibility for my health during the yoga classes, including any injuries.I will inform my yoga teacher of any medical changes.
*
PRINT NAME
Today's date
*
-
Day
-
Month
Year
Date
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