Healthy Being Yoga  -  Health Assessment

Certain postures and practices in yoga need to be modified and avoided if specific health issues are present. In order to support you in safe yoga practice, please complete and return this form prior to commencing classes. If your health status should change at any time, please inform me at the beginning of class. Thank you.

Name …………………………………………………………………………………….                                            

 D.O.B. ……………………………….

Address ……………………………………………………………………................................................

Phone (Day) ………………………                          Mobile ………………………………

Email Address.................................................................................................................................................

Emergency Contact (Name and Phone Number)

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Have you attended other yoga classes? If so, what type?

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Are you allergic to essential oils or incense? ………………………………………………………

What would you like to gain from yoga classes? ………………………………………………… ........

Please tick if you have any of the following:

□   Hearing Issues                            □   High/Low Blood Pressure                      □   Diabetes

□   Back Injuries                               □   Neck/Shoulder Injuries                           □   Joint Pain/Arthritis

□   Knee/Ankle Injuries                   □   Hip Injuries                                                 □   Recent Surgery

□   Osteoporosis                              □   Glaucoma/Detached Retina                 □   Cardiac Problems

□   Respiratory Disorders               □   Hernia/Gastric Ulcers                             □   Current Sciatica

□   Depression/Anxiety                   □   Are You Pregnant?                                    □   Other, please specify

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I declare the above information is accurate and I agree to alert my yoga teacher to any issue that may affect my ability to practice yoga safely. I understand all instructions in class are given only as a guide and I accept responsibility for myself.

Signature ……………………………………………                Date ………….......................................