Health Questionnaire

If you are attending a class for the first time, would you please either print or download and print and fill in our Health Questionnaire.

Please bring this with you to the lesson, many thanks.

Class.............................

Health & Information Questionnaire

Date:..............

All information given will be treated in the strictest confidence and stored in accordance with Data Protection legislation.

Name ................................................................................................................DOB:........................

Address ....................................................................................................................................

Telephone Number Home ............................................. Mobile .............................................

e-mail (block capitals) ........................................................................................................................................

Emergency contact name and tel. no ....................................................................................

Are you new to Yoga? ..........................................................................................

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

How regularly do you do this?………………………………………………………………………………………

Any Food allergies or Requirements?…………………………………………………………………………

The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions that require special attention. If you are unsure please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions.

These conditions require specific modifications to your yoga practice. If yes, please give details.

  • Abdominal disorder or recent surgery........................................
  • Arthritis (osteo or rheumatoid).............................................
  • Back pain (if known cause please state).....................................
  • Knee problems.............................................
  • Hip problems..............................................
  • Shoulder or neck problems...................................................
  • Heart disorders.............................................................
  • High blood pressure.........................................................
  • Low blood pressure..........................................................

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

  • Asthma..............................................
  • Diabetes............................................
  • Auto-immune disorder (e.g. M.E. M.S. Lupus etc).............................................
  • Epilepsy...................................................................
  • Anxiety/depression.........................................................
  • A sensory disorder affecting eyes or ears.............................................
  • Balance affecting disorder.................................................
  • Allergies............................................................
  • Other (to be discussed with the tutor)...........................................

Are you /could you be, pregnant, or have you given birth in the last six weeks? Yes/No

Have you had any operations in the last two years?  If yes, please advise/discuss it with Barley. Yes/No

We keep a record of your provided details in accordance with our published Privacy Policy* to keep you up to date on news and announcements. We will not bombard you with unwanted emails and we will not share your contact details with other parties without further consent from you. ( * Our privacy policy is available on the website at https://barleyyoga.co.uk/privacy) Do you agree to Barley Yoga & Dance recording your details? Yes/No

We would like to register you on the 'Momoyoga' secure database, a third-party site that we use to manage bookings and notify you of changes and cancellations. Do you agree to being registered on Momoyoga? Yes/No

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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.

Name (please print)…………………………………… Signed……………………………………………