Yoga Health Questionnaire

Your full name

Your Email

Age

Birth Date

Address

Phone number

Occupation

Emergency Contact

Have you ever had or do you have?if yes Checkboxes
High blood pressureAny heart/stroke conditionAsthma/breathing difficultiesPain/tightness in chestMajor injuries/operationsPounding, palpitating heartBack painNeck/shoulder painRegular headachesArthritisBroken bonesKnee/ankle problems
If yes to any above, please describe, in detail:

you are not sure if you should do yoga because of any health issues, your doctor will be able to advise you.
Ladies, are you pregnant? if yes tick the box.
Yes i am
Due Date:

In the early stage of pregnancy, it is not recommended to begin a yoga practice. After 12 weeks of pregnancy there will be modifications you can incorporate. Towards the end of your pregnancy it is also recommended to suspend your practice. Listening and connecting to your body will also tell you when to stop as it could be earlier for you.
How did you find about Youtopia Yoga?

What do you want to get from practicing Yoga?

During the class listen to the instructions carefully and always let common sense prevail. Yoga is non-competitive.

Statement: I have read and understood the foregoing and answered all the questions to my satisfaction. In consideration, I hereby waive the right to all and any claims against the teacher for any injury or adverse change in my state of health arising directly or indirectly from my participation in classes.
Tick box
Date:

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