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Health Questionnaire

For new students, please complete this form before coming along to class for the first time. Information held is confidential.

First name*

Last name*

Email*

Phone*

Age Group*

<18

18-29

30-39

40-49

50-59

60-69

70+

Which town do you live in?*

Please provide details of who we should contact in the event of an emergency and please state their relationship to you.*

Have you attended a yoga class before?*

Yes

If yes, which style (if known) and for how long?

What are your main reasons for wanting to practise yoga?*

How did you hear about these classes?*

Do you have any of these health conditions?*

High blood pressure

Low blood pressure

Arthritis

Diabetes

Epilepsy

Heart Problems

Asthma

Depression

Eye Problems

Recent Fractures/Sprains

Recent Operations (in the last two years)

Back Problems

Knee Problems

Shoulder/Neck Problems

Hip Problems

Abdominal Problems

Disorders Affecting Balance

Recent Pregnancies

Are You Pregnant?

None of the above

If you answered Yes to any of the above, please provide details here (if relevant)

If you have any other conditions which should be brought to the attention of the yoga teacher, and/or which might affect your mobility and/or may be likely to cause you concern when doing yoga, please provide details here.

I understand this information is for the guidance of the yoga teacher only and I acknowledge that I exercise at my own risk and take full responsibility for my health during the yoga classes, including any injuries. I will immediately inform my yoga teacher of any medical changes that may affect my ability to exercise.

Signature*

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Date*

Day

Month

Year

Samadhi Yoga, Health & Wellness

samadhiyogauk@gmail.com

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