Have you ever practiced yoga or Nia before?

ADDRESS:

Where did you hear about this class?

EMAIL: OCCUPATION:

Your mobile: Your Home Tel:

Doctor’s name, Surgery and tel. no. if known:

Please give an Emergency Contact Name : Emergency Contact’s number :

Registration and Health Questionnaire

I fully understand the health questions and should there be any change to my health I will notify my instructor immediately. If I answered yes to any questions I must seek doctor’s confirmation that I am fit to commence any yoga/ Nia programme.

Signed (if under 16 by parent or guardian): Date:

 

PLEASE ANSWER – YES or No and if necessary, in more detail on the back of this form Do you NOW OR have you EVER suffered any of the following?

 

1. Back or neck trouble?

11. Eye or Hearing problems?

2. Difficulty with physical exercise?

12. Foot Health Problems?

3. Advised by your doctor not to exercise?

13. Migraine?

4. Joint mobility problems?

14. Hiatus Hernia?

5. Respiratory problems? 5.A. Do you Smoke?

15. Mental Health Problems?

6. Heart problems, chest pain or stroke?

16. Are you currently taking any medication?

7. Diabetes?

17. Are you pregnant/ Breast feeding?

8. Have you had an X-ray or scan of your back?

18. Given birth within the past 6 months?

9. High or Low Blood pressure? 9.A. Often feel faint or dizzy?

19. Recent surgery (last 2 years)?

10. Epilepsy?

20. Any other relevant information regarding health?