Brenda's Yoga - Health Questionnaire & Consent Form for New Students

Brenda's Yoga - Health Questionnaire & Consent Form for New Students

The purpose of this questionnaire is to help us better understand your fitness and health level to address your general expectations from our yoga classes.
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Health Information
Please answer the following questions to the best of your knowledge:
Do you have any medical conditions or concerns that you believe may affect your ability to participate in a Yoga class? (e.g., heart conditions, epilepsy, diabetes, asthma, arthritis, back pain, pregnancy, etc.)

YesNo
If yes, please provide details:
Are you currently taking any medications or supplements?

YesNo
If yes, please list
Have you undergone any recent surgeries or medical procedures?

YesNo
If yes, please provide details
Do you have any allergies (e.g., food allergies, skin allergies, etc.)?

YesNo
If yes, please specify
Benefits of Yoga: Yoga is believed to promote relaxation, reduce stress, alleviate pain, and enhance overall physical and emotional well-being. However, individual experiences may vary, and there are no guaranteed outcomes.

Risks and Limitations: Please be aware that proper care shall be taken for your well-being and safety, however it is important to realize it is your responsibility to adjust your practice to avoid injury.
Yoga Class Consent:

I agree to the following: No responsibility can be taken for injuries from, or as a consequence, of my participation in these classes.
Client Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Brenda's Yoga - Health Questionnaire & Consent Form for New Students

Client Information

Health Information