Student Health Questionnaire Form

Your Details

Your Name*:

Date of Birth*:

Your Postal Address*:

Your Home Telephone Number:

Your Mobile Telephone Number*:

Your Email*:

Emergency Contact Name*:

Emergency Contact Telephone Number*:

Have you attended a Yoga class before?*:
YesNo

If yes, how long have you practised Yoga and what style of Yoga have you practised?*:

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.

I do not wish to declare medical 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.

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

Please tick those that apply:

 
Further information:

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:

 
Further information:

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

Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by Yoga practice?*:

Are you/could you be, pregnant, or have you given birth in the last six weeks?*:

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

How regularly do you do this*?

How did you hear about this class?*:

 

Disclaimer

Please read carefully; 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.

Neither your teacher nor the British Wheel of Yoga are qualified to express an opinion that you are fit to safely participate in any British Wheel of Yoga organised sessions or any British Wheel of Yoga trained teacher’s yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt.

All British Wheel of Yoga, Accredited Group teachers or Recognised Teachers are appropriately qualified, with high standards of teaching and best practice. 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 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. Please contact your teacher immediately if your circumstances change or speak with your yoga teacher prior to taking part in a class if you have any concerns. Your teacher will be unable to make modifications or adjustments to the exercises for health conditions or concerns that are not declared. Your teacher will not be responsible where you fail to return the health questionnaire, or where you do not declare a health condition to your teacher or to BWY (whether by returning the questionnaire or in some other communication), and an issue arises as a result.

Please tick the box to confirm the above*:

GDPR Statement

In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so in order 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, please will you indicate below, your agreement, or otherwise, to the following means of communication:

PostEmailTelephone

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

* Indicates required field