HEALTH QUESTIONNAIRE

Health Declaration Form

Please fill out the following health declaration form in order to participate in any of my classes.
The form only has to be filled out once but please do update me on any changes.
All information given will be treated in the strictest confidence and stored in accordance with Data Protection legislation.

First Name

Last Name

Please tick here if you are happy to be contacted by email about my other classes, workshops and retreats

Emergency contact

Emergency contact phone number

The following information is required to ensure your safety.
Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class.

These conditions require specific modifications to your yoga practice;

abdominal disorder or recent surgery
arthritis (osteo or rheumatoid)
back pain (if known cause please state)
knee or hip problems
shoulder or neck problems
heart disorders
high or low blood pressure

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

asthma
diabetes
auto-immune disorder (e.g. M.E. M.S. Lupus etc)
epilepsy
anxiety/depression
sensory disorder affecting eyes or ears
other (to be discussed with tutor)

Have you practised yoga before and if so for how long and what type?

Date

Please tick here if you agree

I agree to take responsibility for my own health and safety whilst participating in the yoga class, whether face to face or remote.

I agree the information given in this form is true to the best of my knowledge.

Thanks for submitting!

HEALTH QUESTIONNAIRE

Health Declaration Form

Please fill out the following health declaration form in order to participate in any of my classes.

The form only has to be filled out once but please do update me on any changes.

All information given will be treated in the strictest confidence and stored in accordance with Data Protection legislation.