Client Health Questionnaire: FIT Yoga

First name*

Last name*

Birthday*

Day

Month

Year

Phone*

Address

Emergency Contact Name*

Emergency Contact Telephone*

Name of Doctors Surgery

Current Medical Conditions

Have you recently undergone any surgery?

Yes

If yes, please give details of your surgery here:

Are you currently on any medication?

Yes

If yes, please give details of your current medication here:

Do you have high or low blood pressure?

Yes

If yes, please give further information here:

Please give any other health information you feel is relevant or would like the teacher to be aware of:

Yoga Experience and Interest

Please tell us about any previous experience of yoga including physical and meditation practice you have:

What interests you about Yoga? (tick as many as you like)

Flexibility

Strength and Posture

Relaxation

Meditation

Joint Care

Breath Work / Pranayama

Stress Reduction

Health Declaration, please tick all boxes to participate in a class or one to one:*

The information I have given on this form is correct.

I have never been told by my GP or any other healthcare professional not to participate in a yoga class or one to one.

If I have any concerns regarding my health before starting a class or one to one I will consult my GP and talk to the yoga teacher before participating.

I understand that my body is my responsibility and should I become uncomfortable or in pain during a class or one to one I should speak to the teacher at the time and ask for suitable variations or rest.

All boxes must be ticked in order to participate.

Signature

Signature field is empty.

This form is strictly confidential and solely for the use of the teacher to help provide a safe environment within the yoga session.

Contact

Nicky Marsh

FIT Yoga

Langport

Somerset

Tel 07568 169116

Email nickytaplin@hotmail.com

Book a Consultation

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