Health questionnaire | Yoga Therapy Hub

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Health questionnaire
Yoga practice is suitable for every age and physical fitness and flexibility. However, there are a number of medical conditions that might require a slight adjustment to the training and special attention from the teacher and the student. Please state your basic medical history in this form, marking “yes” next to conditions you have, and “no“ next to conditions you don’t have.

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Country

Age

Tick relevant boxes below

Blood pressure

Diabetes

Headache, dizziness, fatigue

Asthma or breathing problems

Balance problems

Problems with neck and shoulders

Joint problems

Spine problems (herniated disk, scoliosis, etc.)

Digestive problems

Ear problems

Glaucoma or other eye problems

Chronic diseases (active or dormant)

Osteoporosis

None of the above

Have you ever had surgery?

Do you smoke?

Please answer the following questions if applicable

Are you pregnant?

If yes, do you suffer from high/low blood pressure, gestational diabetes, cervical weakness, symphysis pubis dysfunction?

How many births have you given?

Are your periods regular?

*Women on their period are advised to refrain from certain exercises. Please speak to the teacher before the beginning of class.

** Please note that if you are over the age of 70, you are required to present a doctor’s note allowing you to practice Yoga.

Notes

Please inform the teacher of the above-mentioned conditions in order to better adjust your training and determine whether you need a doctor’s note to participate in classes. I confirm that in case of a change in my health condition, I will inform the teacher.

I confirm that I understand that informing the teacher of the above-mentioned details are essential for practice. I confirm that the practice is my personal responsibility and I will listen to the teacher’s instructions in class.

Upload any relevant documents below

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Date

Signature

By submitting this form, I confirm that the information I have provided is correct.

Thanks for submitting!

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