Today's Date

Name of Course

Course Fee 

Payment status:

Paid / Unpaid

Students are ultimately responsible for their own health and well being, but knowing a few details about you helps us to teach appropriately, lets us know when we may need to adapt practices and gives us a chance to introduce practices of particular benefit to you.

All information written on this form is kept in strictest confidence. It is important to let the yoga teacher know if any of the below changes during the yoga course.

Name

Phone 

Mobile 

Email

Address 

Date of Birth 

Have you ever practised yoga before?

If so for how long approximately?

And how recently?

If possible say why you are coming to yoga class. e.g. relaxation, increased flexibility, health, concentration etc.

Do you suffer from any illness, condition or physical disability? If so please give details.

Have you suffered any injury or undergone an operation in the last two years? If so please give details.

Do you have any of the following? (Tick relevant conditions and give a brief history below):

High blood pressure

Low blood pressure

Back problems, or history of . . .

Dyslexia

Attention deficit disorder

Eating disorders

Epilepsy

Glaucoma

Diabetes

Asthma

Brief History

Do you have any other physical, mental or emotional condition/s that may affect you during class?

Are you prescribed any medication? Please give brief details.

All information you give us will be treated in the strictest of confidence.