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Yoga with Lisa
Enfield & N21
07958 299706
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Student Health Questionnaire Form

    Your Details

    The following information is required to ensure your safety. Whilst Yoga may be practised safely by most people, there are certain conditions which require special attention. If you are unsure, please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions.

    These conditions require specific modifications to your Yoga practice. If yes, please give details below:

    Please tick those that apply:

    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

     

    These conditions may affect your practice and so provide useful information for your tutor. If yes, please give details below:

    Please tick those that apply:

    Asthma
    Anxiety / depression
    Epilepsy
    Respiratory issues
    Sensory disorder affecting eyes or ears
    Diabetes
    Auto-immune disorder (e.g. M.E.,M.S.,Lupus etc.)
    Balance affecting disorder
    Migraines
    Other (discuss with tutor)

     

    I do not wish to declare medical information:


     

    Declaration

    I confirm the above information is correct and that I take responsibility for my own health and safety whilst participating in the Yoga class.

    I also understand that it is my responsibility to:

    • Check with my doctor if I have any difficulties or concerns about my ability to participate in the Yoga class
    • Advise the Yoga tutor of any change in my medical information or ability to participate in the Yoga class
    • Follow the advice given by my doctor and/or Yoga tutor

    Please tick the box to confirm the above*:

    In order to comply with the General Data Protection Regulations, it is necessary to check whether or not you are happy for me to retain your contact details, and to email you information I think will be useful to you, including training and events, and relevant updates. I only hold information when it is necessary 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, can you please indicate below your preference(s) when contacting you.

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    Please note that you are able to amend these choices at any time by contacting me.

    * Indicates required field

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