Pre-Yoga Class Questionnaire Pre-Yoga Class Qustionaire Please complete and submit the form below before your first yoga class. If you have any queries, please e-mail me at ramutesoasis@gmail.com Yoga Questionnaire Name * First Last * Last Email * Phone * No Spaces Emergency Contact Name * First & Last Emergency Contact Number * Please give details of any other physical activity you do To help to ensure your safety when practising yoga, please tick any boxes below that apply to you: * Abdominal disorder or recent surgery Anxiety/depression Arthritis (osteo or rheumatoid) Asthma Auto-immune disorder (e.g. M.E. M.S. Lupus etc) Back pain (if cause known please state) Balance affecting disorder Epilepsy Glaucoma Heart disorders High blood pressure Hip problems Knee problems Low blood pressure Sensory disorder affecting eyes or ears Shoulder or neck problems Other (to be discussed with instructor) None of the above Yoga is safe for the majority of people, however there are certain conditions which require special attention. If you're not sure please consult your GP beforehand. Are you pregnant, could you be or have you given birth in the last six weeks? * Yes No Details of any injuries that could affect your ability to practice yoga: Please tick below to confirm that the information you've provided is accurate, that you agree it's your responsibility to check with your doctor if you have any concerns about practising yoga and that you are responsible for notifying me if any of this information changes: * I confirm the information is correct Would you like to receive occasional e-mails with updates and offers? * Yes No This form collects and stores your details in line with our privacy policy and only for the purposes stated. If you are human, leave this field blank. Submit
