Health Questionnaire for New Students Name * First Name Last Name Age Group please select * Under 15 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80+ Address * Email * Telephone * Emergency contact: Name and telephone * Have you attended a yoga class before? * Yes No If yes, how long have you been practicing yoga? * What aspects and types of yoga interest you, or are you currently practicing? * Asanas (physical postures) Pranayama {breathing work} Meditation Chanting Relaxation Ashtanga yoga Hatha yoga Hot yoga Iyengar yoga Sivananda yoga Vinyasa flow yoga Yin yoga Yoga nidra Other, please specify below The following information is required to ensure your health. Whilst yoga may be practised safely by most people, there are certain conditions that require special attention. If you are unsure, please consult your GP before commencing class. Do any of these health conditions apply to you? * High blood pressure Low blood pressure Arthritis Diabetes Epilepsy Heart problems Asthma Depression Detached retina/other eye problems Back problems Knee problems Neck problems Migraine Recent fractures Recent operations Recent pregnancies None of these Are you, or could you be pregnant? * Yes No Not applicable Do you have any allergies? * Do you have any other conditions which affect your mobility or are likely to cause you concern when doing yoga? If yes, please give details * I take full responsibility for my health during the yoga classes, including any injuries. I will inform my yoga teacher of any medical changes. Disclaimer: Please read carefully before clicking the submit button below. Your submission of this form will be taken to indicate your understanding and acceptance of the following: Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By submitting the questionnaire, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify your teacher of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes. Your teacher is not qualified to express an opinion that you are fit to safely participate in any classes or courses. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. Your teacher is appropriately qualified, with high standards of teaching and best practice. Where possible, your teacher may offer suitable modifications or adjustments and practices to suit different levels of experience and ability. Please always let the teacher know before the class if this is your first time practicing yoga or if you are not confident about your experience and/or ability. Where you are taking part in an online class, please note that the instructor may not be able to see you at all times. Where you have declared a health condition, please contact the teacher before the class if you would like to request that you are provided with suitable modifications or adjustments wherever possible. In all classes whether face to face or online, always follow your teacher’s safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class. GDPR statement In order to comply with the General Data Protection Regulations, it is necessary to check whether or not you are happy for Yoga with Gabriele to retain your contact details, and to send you information that we think may be useful to you, including upcoming classes and workshops, and relevant updates. To ensure that we only communicate with you in the manner of your preferred choice, please will you indicate below, your agreement, or otherwise, to the following means of communication: Please contact me by: * Email Text Thank you very much for filling in this form Thank you!
