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Health Form

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Please take a moment to complete the health form. This enables ourselves and the teachers to know about any ailments, injuries or medical conditions that we need to be aware of.

Name *

First

Last

Age *

Address inclusive of postcode *

Mobile Number *

Email *

Emergency Contact Name & Telephone No *

Have you ever practised yoga before, either at home or in a class *

What other physical activity do you take part in (eg. gym work, jogging, swimming aerobics)? *

Select any of these conditions if they apply to you

Abdominal disorder or recent surgery
Arthritis (osteo or rheumatoid)
Back pain (if known please state
Knee, hip or pelvic problems
Shoulder or neck problems
Heart disorders
High or Low blood pressure
Asthma
Diabetes
Auto-immune disorder (e.g M.E M.S etc)
Epilepsy
Anxiety/depression/post-traumatic stress
Problems with eyes, ears, vision or hearing
Balance issues
Anything else you wish to inform us about

If you have anything else you wish to inform us about please do so here

Do you have past injuries that still trouble you? Or any other medical conditions not covered above that you feel your yoga teacher should know about? *

If yes please provide details

Are you pregnant? *

Yes (if yes we will contact you with another form to complete)
No

Have you given birth within the last 12 months? *

Yes (if yes we will contact you with another form to complete)
No

Signed *

I confirm that the above information is correct. I 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 changes in my physical and mental health. Follow the advice given by my doctor and/or yoga tutor.

Date *

Where did you hear about Cornwall Yoga Centre?

Do you wish to join our mailing list and receive our newsletter containing info about new classes/workshops and events? *

Name

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