Student Health Questionnaire

To be completed by yoga class participants for face to face and remote teaching. All information given will be treated in the strictest confidence and stored in accordance with General Data Protection legislation.

Date of Birth(required)

Emergency Contact(required)

Emergency Contact Number(required)

How did you hear about me?

Have you attended a yoga class before?(required)

Yes No

Please give any information on previous yoga experience:

Please indicate if any of the following medical conditions apply to you, this is so suitable adjustments can be given in a class. Please remember you know your body best and if something doesn't feel right, don’t continue with that movement. If you are unsure, please consult your GP before commencing class.

Please tick this box if you do not wish to declare medical information. (Please be aware that I cannot give any modifications or alternatives that may be appropriate, for conditions that have not been declared.)

Have you had any recent operations (in the last two years)?(required)

Yes No

Are you /could you be, pregnant, or have you given birth in the last six weeks?(required)

Yes I am Yes I could be I have given birth in the last six weeks No

Please tell me about your general wellbeing, sleeping habits, and stress:

Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other?(required)

What would you like to gain from my yoga classes?

Any additional info:

Your submission of this form will be taken to indicate your understanding and acceptance of the following:
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 your teacher of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes.
Your teacher is not qualified to express an opinion that you are fit to safely participate in any yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. Where possible, your teacher may offer suitable modifications or adjustments and practices to suit different levels of experience and ability.
Please always let the teacher 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 the instructor may not be able to
see you at all times. Where you have declared a health condition, please contact the teacher 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 your teacher’s 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.

I confirm my understanding and acceptance of this health questionnaire and its disclaimer: