Health Questionnaire

Full name

First NameLast Name

Date of Birth

Date

E-mail

example@example.com

Mobile No

Area CodePhone Number

Emergency contact

First NameLast Name

Mobile No

Area CodePhone Number

Have you practiced yoga before?

No I am a complete beginnerI have done a littleI did practice regularly but not for a whileYes I practice regularly

The following information is required to ensure your safety. Whilst yoga may be practiced 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:

	Yes	No
Abdominal disorder or recent surgery
Back issues/ pain
Hip issues/ pain
Knee issues/ pain
Shoulder or neck issues/ pain
Arthritis
Low or high blood pressure
Other

Further Information

These conditions may affect your practice and so provide useful information for your teacher

	Yes	No
Respiratory issues e.g. asthma
Epilepsy
Autoimmune disorder e.g. ME or MS
Balance affecting disorder
Other

Further Information

DECLARATION

I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the yoga class whether face to face or remotely.

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 my yoga teacher 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 teacher

Initials

Health Questionnaire

General Data Protection Regulations