Yoga - Pre-Class Questionnaire

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Yoga Experience
Please Select
Complete Beginner
A Little Some Time Ago
Regular Practitioner
4
Do You Currently Have, or Have You Ever Had:
Please Select
Asthma
Back or Spine Injury
Blackouts or Fainting
Cancer
Diabetes Mellitus
Difficulty Breathing
Epilepsy, Seizures, or Convulsions
Head Injury with Loss of Consciousness (in the Past Five Years)
Heamophilia or Any Blood Disorders
Heart Attack
Hernia
High Blood Pressure
High Cholesterol
Lung Disease (any Form)
Major Surgery, Especially on the Spine, Skull or Abdomen?
Mental, Psychological or Personality Disorders
Migraines or Headaches
Osteoporosis
Recent Injuries , Even if You Feel 100% Recovered
Recreational Drug Use or Treatment for Addiction
Recurrent Back Problems
Surgery (in the Last 2 Years)
Thrombosis
None Of The Above :-)
5
Please Give More Information
6
What Would You Like To Accomplish Through Yoga
7
Are You Currently Taking Any Prescribed Medications
8
Do You Have Any Other Condition You Would Like to Mention
9
Is There Any Health Condition You Would Like to Address with These Yoga Sessions
10
Could You Be Pregnant or Are You Attempting to Become Pregnant
Yes
No
11
How Much Do You Exercise
Please Select
Never
Rarely
Sometimes
Regularly
12
How Would You Rate Your Ability To Relax
1
2
3
4
5
Impossible
Effortless
13
How Would You Score Your Stress Levels
1
2
3
4
5
Low
Very High
14
Please verify that you are human* This field is required.
Should be Empty: