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Yoga Therapy Health Questionnaire and Waver Form

Thank you for filling out this health questionnaire and waver form 

for Yoga Therapy

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Dear Yogi,

Yoga Therapy has the goal to ameliorate both physical and mental pain and distress through the ancient teachings of yoga and the modern knowledge of medical science combined. In order to make sure that our sessions are most effective, it is critical that I know a little more about you and your health. The information you will share here will allow me to plan our weekly practice with your safety in mind, and that of your fellow yogis.

 

I know this is a little lengthy, but you will only have to fill it once-a-year, and it is for your safety!

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YOUR INFORMATION IS AND WILL REMAIN CONFIDENTIAL

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I will contact you if I see any concerning information that I feel I need to discuss with you directly.


Health QUESTIONNAIRE AND Waiver FORM

for 
Yoga Therapy COURSE

To register for this class please fill out the following questionnaire and medical waver - It is for your safety. Thank you!

Have you filled out this form since September 2021?
1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2) Do you feel pain in your chest when you do physical activity?
3) In the past month, have you had chest pain when you were not doing physical activity?
4) Do you lose your balance because of dizziness or do you ever lose consciousness?
5) Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or a heart condition?
7) Do you know of any other reason why you should not do physical activity?

More in detail

Medical questions
Please check anything you are currently experiencing:

Cardiovascular
Musculoskeletal
Gastrointestinal
Circulatory
Respiratory
Neurological
Endocrinological

Lifestyle questions 
Please check all that applies to you:

How is your sleep?
How is your diet?

Thanks for submitting!

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