Pre-Yoga Questionnaire Name(required) Email(required) Emergency contact name and phone number:(required) Please give details of your yoga experience, if any… Do you participate in any other physical activity? Please give details… The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class. If you have any of the following medical conditions tick the box… (required) abdominal disorder or recent surgery arthritis (osteo or rheumatoid) back pain knee problems hip problems shoulder or neck problems heart disorders high blood pressure low blood pressure asthma diabetes auto-immune disorder (e.g. M.E. M.S. Lupus etc) epilepsy anxiety/depression sensory disorder affecting eyes or ears balance affecting disorder none Other conditions… Are you /could you be, pregnant, or have you given birth in the last six weeks? (required) Yes No Please give details of any injuries – old or recent – that could impact your ability to practice yoga…(required) Are you allergic or prefer not to be in contact with pure essential oils? Yes No In yoga we offer hands on adjustments to assist and align and help get you further into the stretch if appropriate and also to assist relaxation. Are you happy to receive hands on support? No thank you Yes please Tick this box to confirm that the information you have given in this form is accurate, and that you understand it is your responsibility to check with your doctor if you have any difficulties or concerns about your ability to participate in a yoga class, and that you are responsible for notifying me if any of this information changes. I confirm the information is correct. (required) By submitting this form you confirm you have read and accepted our terms and conditions, and that you accept that One w/ Earth is not liable for any injury, or damages, to person or property, resulting from the taking part in this yoga class. I agree to these terms and conditions. (required) Submit Δ Share this:TwitterFacebookLike this:Like Loading...
One w/ Earth 