Yoga Health Questionnaire

Yoga Health Questionnaire

Please complete the form to the best of your knowledge and be assured that it will be treated in the strictest confidence. The questionnaire is designed to make sure that you can practice safely. If there is anything you are unsure about or would like to chat through, please get in touch.

Before you fill out this questionnaire and send the form back to Nurtured Soul, we advise you read the privacy policy so you understand and accept what happens to your data. By you forwarding the questionnaire on to us, we will assume you accept the privacy policies stated.

First name

Last name

Email

Date of birth

Day

Month

Year

Address

Phone

Occupation

Preferred Contact

Email

Phone

Emergency Contact Information Full name / Address / Email / Phone number / Relationship to you

Are you receiving any treatment for diagnosed medical conditions?

Yes

No

Are you taking any prescribed medication?

Yes

No

Have you had a major injury in the last 5 years?

Yes

No

Have you had any recent operations?

Yes

No

If yes to any of the above, please give more details here

Is there anything you would like me to know about?

Is there anything that concerns you or that you would be interested in?

I declare that the info I’ve provided is accurate and complete.

Yes, keep me updated about news and events.

Declaration

Please tick if you agree with this statement

By ticking this box, I am declaring that I have disclosed to my yoga teacher all information regarding my health relevant to the practice of Yoga. I take full responsibility for all applications of yoga I practice in the class. I fully understand that the recommendations, ideas or techniques expressed and described in the yoga classes are not a substitute for the advice of a qualified medical practitioner. Any use of recommendations, ideas and techniques are at my sole discretion & risk.

Signature

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