SAM SCHOLES YOGA

Health Questionnaire

First name

Last name

Date of birth

Day

Month

Year

Phone

The information you supply will only be used for the purpose of contacting you regarding classes held by Sam Scholes Yoga. You will be invited to join the WhatsApp community and are free to decline or remove yourself from the group if you do not wish to join.

What is your main reason for attending a yoga class?

Have you attended a yoga class before?

Yes

If yes, how long have you practiced? And what style of yoga (if known)?

How did you hear about this class?

From time to time I would like to email you with news and updates. If you would prefer not to be included in my mailing list please tick the box below

I do not want to receive new by email

The following information is required to ensure your safety. Whilst yoga may be practiced 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. Please tick any that apply.

These condition require specific modification to your yoga practice. If yes, please give details:

Abdominal disorder or recent surgery

Arthritis

Back pain (please state cause if known)

Knee problems

Hip problems

Shoulder or neck problems

Wrist problems

Heart disorder

High blood pressure

Low blood pressure

Further information:

These conditions may affect your practice and so provide useful information for your tutor:

Asthma

Diabetes

Auto-immune disorder

Epilepsy

Anxiety / depression

Sensory disorder affecting eyes or ears

Balance affecting disorder

Other (to be discussed with tutor)

Further information:

Are you/could you be pregnant, or have you given birth in the last six weeks?

Yes

Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by yoga practice? If yes, please provide details:

Have you had any recent operations (in the last two years)?

Yes

If yes, please advise what the operation was:

Declaration

I confirm the above information is correct.

I understand that it is my responsibility to:

Check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class
Advise the yoga tutor of any change in my medical information
Follow the advice given by my doctor and/or yoga tutor

I understand that I am participating and undertaking all activities at my own risk.

I understand that under no circumstances is the yoga tutor or the hosting venue liable for any incident, accident or health issue that may occur or arise.

Signature

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