Health Questionnaire
This questionnaire has been designed to help you to enjoy your session safely. All information given will remain private and confidential.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Date of Birth
What is your Profession
Gender
Female
Male
Nonbinary
Who to contact in case of emergency
Emergency contact - Telephone number
Name of session you are attending
Please Select
Yoga Class
Yoga Aerial Trapeze
New Year Retreat Day Cleanse - Nourish - Recharge
Have you practiced yoga before .. and if so what style?
Have you had any major injury in the last 5 years:
Yes
No
If you answered yes above, please give more details
Are you taking any prescribed medication:
Yes
No
If you answered yes above, please give more details
Are you receiving treatment for any diagnosed medical conditions:
Yes
No
If you answered yes above, please give more details
Have you had any recent operations:
Yes
No
If you answered yes above, please give more details
The following conditions require specific modifications to your yoga practice. Please indicate below whether or not you have any of the following medical conditions.
Abdominal disorder or recent surgery
Arthritis (osteo or rheumatoid)
Unspecified back pain/ problems
Spinal injury
Joint replacement
Knee problems
Hip problems
Shoulder problems
Neck problems
Heart disorders
High blood pressure
Low blood pressure
Please indicate if you ever experience any of the following symptoms.
Unusual shortness of breath with very light exertion
Pain, pressure, heaviness or tightness in the chest area
Unexplained pain in the abdomen, shoulders or arm
Severe dizzy spells or episodes of fainting
Regular lower leg pain during walking that is relieved by rest
Palpitations or irregular heartbeats
Are you currently pregnant or have you given birth in the last 6 months:
Yes
No
Any Dietary Requirements or Allergies? Please give details below:
Are you vegan, vegetarian or pescatarian?
Vegan
Vegetarian
Pescatarian
None of the above
Would like to be on the mailing list?
Yes
No
I agree that I have read and understood the health questionnaire and confirm that I have answered all questions honestly and that the information given is correct and I acknowledge that I exercise at my own risk.
I agree
Signature
Submit
Submit
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