health questionnaire

All information given will be treated in the strictest confidence & stored in accordance with GDPR.

It is entirely up to you what, or how much, information you disclose. You can leave all or any sections blank, but we draw your attention to the Terms & Conditions because you must be responsible for your own health if you do not disclose.

1. Name

First Name

Last Name

2. Email

3. Phone

4. Emergency Telephone

5. Relevant Health Issues

Have you had any major health problems in the past or are you currently seeing a health practitioner? (Such problems might include high or low blood pressure, recent surgery, epilepsy, diabetes, serious injury or accident, asthma, ulcers, hernias, arthritis, chronic disease, problems with the back, the heart, knees, eyes, ears or mental health, or anything else you may wish to make the teacher aware of.)

6. Please tick this box if you DO NOT wish to declare physical and/or mental health information

(It is your right to withhold information, but we must inform you that if you do not disclose your health status, your teacher cannot give modifications or alternatives for physical conditions that have not been declared, and will be unaware of anything that might cause emotional distress or otherwise exacerbate any mental health issues.)

Nothing to declare

7. How did you hear of this class?

8. Have you attended a yoga class before? If so, how long did you practice?

9. If you are pregnant, how many weeks

10. Are there any particular aspects of yoga that interest you?

(Yoga covers a wide range of disciplines which include flexibility, strength, stamina, breathing, relaxation, mental awareness, spirituality, meditation.)

11. Terms & Conditions

Please read carefully, your submission of this form will be taken to indicate your understanding & acceptance: • Neither your teacher nor the BWY are qualified to express an opinion that you are fit to safely participate in any BWY organised sessions or any BWY trained teacher’s yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. • All BWY teachers are appropriately qualified, with high standards of teaching & best practice. Where possible, your teacher may offer suitable modifications or adjustments & practices to suit different levels of experience & ability. • Where you have declared a health condition, please contact the teacher before the class if you would like to request suitable modifications or adjustments. • Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any physical or emotional discomfort, please do not continue. If you do not return this questionnaire to your teacher prior to taking part in one of our classes, your teacher will assume that you DO NOT have any existing health conditions or concerns to declare.

I agree

12. Date

YYYY

13. GDPR (General Data Protection Regulations)

In order to comply with GDPR, I need to check whether you are happy for me to retain your contact details, & send you information that I think may be useful to you, including training, events & updates. I only hold information when it is necessary to do so & when you have given me permission. Please indicate your agreement, or not to the following means if communication.

Telephone

Post

health questionnaire

Hatha Yoga With Vicki