Yoga Day Retreat Health Questionnaire

Name*
First Last
Email*
Phone*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Have you done yoga before?*
- No, never
- Yes, but a while ago
- Yes, but not regularly
- Yes, I'm currently practicing
If Felicity doesn't already know your practice, please give details about your experience of yoga (e.g. years practicing, type of yoga and regularity)
Do any of these health conditions apply to you?
- High blood pressure
- Low blood pressure / fainting
- Arthritis
- Diabetes
- Epilepsy
- Heart problems
- Asthma
- Depression
- Anxiety
- Detached retina /other eye problems
- Recent fractures /sprains
- Recent operations
- Back problems
- Knee problems
- Neck problems
- Hip problems
- Carpal Tunnel Syndrome
- Sciatica
- Recent pregnancy (how many months postnatal?)
- Currently pregnant (how many weeks?)
- Currently undergoing fertility treatment
- Other conditions (please state below)
Please give details about the conditions above (if applicable)
Please give details of any allergies that you have (if applicable)
Please give details of any dietary requirements or preferences that you have (if applicable). All meals on the retreat will be vegetarian, low in gluten and refined sugar. We can cater for any special diets.
Please read the following and confirm*
- I confirm that, to the best of my knowledge, these answers are accurate and I know no reason why I should not participate in a yoga retreat. I acknowledge that all physical activities involve risk of personal injury and I agree to take responsibility for my health and wellbeing, including any injuries during the yoga classes. I will inform my yoga teacher of any medical changes.
- Please tick here if you would like to subscribe to our e-newsletter to receive details about our classes, workshops and retreats