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YOGA HEALTH QUESTIONNAIRE
Name
*
First
Last
Email
*
Phone
*
Which class are you first planning to come to?
*
Yoga for Beginners
Hatha
Hatha Flow
Gentle Hatha
Vinyasa Flow
Restorative
Workshop
On which date are you first planning to attend?
*
Day
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Year
2024
2023
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1925
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1923
1922
1921
1920
Have you done yoga before?
*
No, never
Yes, but a while ago
Yes, but not regularly
Yes, I'm currently practicing
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 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 class. 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 class. I will inform my yoga teacher of any medical changes.
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