Health Form - 121 Yoga for Teachers and Students

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Health Form

STUDENT and HEALTH QUESTIONNAIRE
to be completed in when joining yoga class

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

(Fields marked with an * must be completed.)


Address:







Emergency contact:




Yes
No






The following information is required to ensure your safety. Whilst yoga may be practised safely by the majority of people, there are certain conditions which 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.

 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


 asthma
 diabetes
 auto-immune disorder (e.g. M.E. M.S. Lupus etc)
 epilepsy
 anxiety/depression
 sensory disorder affecting eyes or ears
 balance affecting disorder
 other (to be discussed with tutor)

YesNo

YesNo


Yes
No


 Please tick this box if you do not wish to declare medical information



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