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Menu
Home
About me
Timetable
Competition Time!
Class styles
1:1 Sessions
Corporate
Yoga for Sports
Personal training
Gallery
FAQ's
Blog
Contact
CLIENT TRACEABILITY AND HEALTH QUESTIONNAIRE
To be completed before taking part in 1:1, 1:2 or small group sessions.
Name
*
First Name
Last Name
Email
*
The email you provide will be used to update you of news and classes but you can unsubscribe from these updates at any time.
Phone number
*
Please provide your phone number. This will only be used for COVID-19 traceability if required.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Telephone Number
Are you taking part in a 1:1 or small group session?
*
1:1
Small group (2 or more participants)
Do you have any health conditions that may be affected by practising Yoga?
Please tick any that apply.
Abdominal disorder or recent surgery
Anxiety/depression
Arthritis (osteo or rheumatoid)
Asthma
Auto-immune disorder. Eg. M.S. Lupus, M.E.
Back pain
Diabetes
Epilepsy
Knee problem
Hip problem
Heart disorder
High blood pressure
Low blood pressure
Sensory disorder affecting eyes, ears or balance
Shoulder or neck problem
Other conditions, injuries or surgeries in the 2 years - Please add details in the comment box below.
None of the above
Please add detail of recent injuries/surgeries/concerns that you feel may affect your Yoga practice
Are you pregnant or have you given birth in the last 6 weeks?
*
Although Yoga is suitable for pregnant women, some movements may have to be modified.
Yes
No
I understand it is my responsibility to check with my doctor if I have any difficulties or concerns about my ability to take part in the Yoga sessions and that I participate at my own risk.
*
Yes
Thank you!
