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Yoga Health Questionnaire

The questionnaire has to be filled to attend a yoga class with us.

By filling this questionnaire you are also giving us permission to email you and if you do not want to receive mail from us when you get your first email you can unsubscribe. 🙂

    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: