Health Questionnaire

health questionnairePlease complete the following questionnaire. If you cannot for some reason, don't worry, you can fill in a printed version before your first class. If you do not complete online please arrive at least 15 minutes before your first class so that you have time to complete and discuss with your instructor.

November 28, 2020 Health Questionnaire

The following information will enable your yoga instructor to offer you the safest and most appropriate yoga postures for your current level of health. All information given on this form will be treated as strictly confidential.

Full Name
Your email
Your phone number.
Suburb or town.
Your date of birth.
Whom should we contact in an emergency?
What phone number can we reach them on?
Have you done yoga before?
Medical History

Have you had any of the following?
Repetitive Strain Injury (RSI)
Blood pressure
Do you have any other health condition, past or present, that may cause difficulty or pain?
If yes, please specify:
Have you had any surgery in the last 12 months?
Are you, or do you think you may be pregnant?
If yes, in what stage of pregnancy are you? Trimester:
Signs and Symptoms

Do you now, or have you ever had any significant or memorable instances of the following?
Muscular pain
Wrist pain/injury
Neck pain/injury
Shoulder pain/injury
Ankle pain/injury
Back pain/injury
Knee pain/injury
What are your reasons for wanting to take yoga classes? (Choose one or more).

Please read the following carefully. You will be asked to sign this statement when you attend your first class.

I understand that the instructions given throughout the classes are intended for guidance only. I understand that while all due care will be taken by the instructor, they cannot be responsible for my improper practice at any time. To ensure that no personal injury occurs, I agree to adjust my practice to my limitations and the decision to perform any postures or actions remains mine. I declare that I will take full responsibility for myself during the classes. I will notify the instructor before each class begins of any recent injury, illness, surgery or pregnancy.

Thank you for submitting your answers. We will contact you soon to discuss your attendance.