Vicks Yoga

Name:

Date of Birth:

Address:

Contact Number:

Email:

Have you practiced Yoga before?

Yes / No

The following information is required to ensure your health. Whilst yoga may be practised safely by most people, there are certain conditions that require special attention. If you are unsure, please consult your GP before commencing. Please indicate with a  below whether or not you have any of the following medical conditions and then provide further information:

 Abdominal disorder or recent surgery

 Unspecified back pain/ problems

 Joint replacement

 Hip problems

 Heart disorders

 Low blood pressure

 High blood pressure

 Arthritis (osteo or rheumatoid)tick

 Spinal injury

 Knee problems

 Shoulder or neck problems

These conditions may affect your practice and so it will be useful for your teacher to be aware of them:

 Asthma

 Diabetes

 Anxiety/depression

 Auto-immune disorder (e.g. M.E., M.S., Lupus etc.)

 Epilepsy

 Balance affecting disorder

 Respiratory issues

 Migraine

 Sensory disorder affecting eyes or ears

 Other (discuss with teacher)

Please initial if you do not wish to declare medical information.

 I do not wish to disclose my medical information and I am aware that the yoga teacher cannot give any modifications or alternatives that may be appropriate, for conditions that have not been declared.

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

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?

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

No / Yes / Not Applicable

Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other?

Do you have any difficulty getting up and down  on a yoga mat?

What would you like to focus on for your Yoga classes or sessions?

Please read the disclaimer carefully:

 I agree to the disclaimer

Disclaimer

Please read carefully; your submission of this form will be taken to indicate your understanding and acceptance of the following:

Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By submitting the questionnaire, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify your teacher of any changes to your responses in this healthcare questionnaire before participating in sessions or classes subsequent to those changes.

Neither your teacher nor the Yoga Alliance are qualified to express an opinion that you are fit to safely participate in any Yoga organised sessions, tuition or guidence. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt.

Please always let the teacher know before the class if this is your first time practicing yoga or if you are not confident about your experience and/or ability. Where you are taking part in live-streamed classes, please note that the instructor may not be able to see you at all times. Where you have declared a health condition, please contact the teacher before the class if you would like to request that you are provided with suitable modifications or adjustments wherever possible.

In all classes whether face to face or live streamed remote, always follow your teacher’s safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class.

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