Health Form If you would like to attend any of the classes/sessions, please fill out the form below. Name(required) Date of Birth Address Phone Number(required) Email(required) Confirm Email(required) Emergency contact: name(required) Emergency contact: phone number(required) Emergency contact: email(required) Have you practiced yoga before? Yes No If yes, what style and how much experience do you have? These conditions require specific modifications to your yoga practice.This 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 class. Please indicate in the boxes whether or not you have any of the above 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 Arthritis (osteo or rheumatoid) Spinal injury Knee problems Shoulder or neck problems High blood pressure Other Please give details of the above as necessary These conditions may affect your practice and so it will be useful for me to be aware of them: Asthma Anxiety/Depression Diabetes Epilepsy Respiratory issues Sensory disorder affecting eyes or ears Auto-immune disorder (e.g. M.E., M.S., Lupus etc.) Balance affecting disorder Migraine Other Please give details of the above as necessary Please tick this box if you do not wish to declare medical information.Please be aware that your yoga teacher cannot give any modifications or alternatives that may be appropriate, for conditions that have not been declared. I do not wish to declare medical information Have you had any recent operations? (In the last two years) Yes No Please give details of recent operations, old injuries or other medical conditions that affect you in any way Are you /could you be, pregnant, or have you given birth in the last six months? Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other? If yes, how often? GDPR Statement In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, please will you indicate below, your agreement, or otherwise, to the following means of communication.You can unsubscribe from receiving marketing emails from me at any time from following the link in any Mailchimp email from me.(required) Email Phone Disclaimer: 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 me of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes. Neither your I, nor the British Wheel of Yoga are qualified to express an opinion that you are fit to safely participate in any British Wheel of Yoga organised sessions or any British Wheel of Yoga trained teacher’s yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. All British Wheel of Yoga instructors are appropriately qualified or British Wheel of Yoga Accredited teachers, with high standards of teaching and best practice. Where possible, I may offer suitable modifications or adjustments and practices to suit different levels of experience and ability. Please always let me 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 I may not be able to see you at all times. Where you have declared a health condition, please contact me before the class if you would like to request that you are provided with suitable modifications or adjustments wherever possible. Please note, where you are taking part in a pre-recorded class, you will not be able to request specific adjustments or modifications. In all classes whether face to face, live streamed remote or pre-recorded remote, always follow my 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.(required) I confirm my understanding and acceptance of this health questionnaire and its disclaimer Send Δ