Health Assessment

The following information is required for your safety. If you have any specific medical concerns or have an existing health condition it is best to consult with your GP before attending a yoga class. Please note that the information that you will be sharing below will be private and highly confidential.  

    Client Contact Information

    Emergency Contact Information

    Medical History

    Have you had a major injury in the last 5 years: YesNo

    If Yes, please give more details here:

    Are you taking any prescribed medication: YesNo

    If Yes, please give more details here:

    Are you receiving treatment for any diagnosed medical conditions: YesNo

    If Yes, please give more details here:

    Have you had any recent operations: YesNo

    If Yes, please give more details here:

    Medical Conditions

    The following conditions require specific modifications to your yoga practice. Please indicate below
    whether or not you have any of the following medical conditions.

    Please indicate if you ever experience any of the following symptoms.

    Are you currently pregnant or have you given birth in the last 6 months: YesNoNot applicable

    Student Declaration
    I can confirm that I have answered all questions honestly and that the information given is correct. I agree to inform the yoga teacher if any of the above changes.

    Interested for an exclusive yoga sessions to your private group?