Registration Form
Please complete both parts of this form to
enable me to have a brief overview of your
details. This information will be treated as confidential.
Thank you.
Personal details
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Name |
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Address
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Telephone |
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Email address |
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Date of birth |
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General Health
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How is your general health? |
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Are you on any medication? If yes, please give details
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Do you suffer from breathlessness,
headaches or dizziness?
If yes - how often and are there any triggers?
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Are there any areas of
the body where you feel pain or discomfort? If so, where?
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Do you or have you ever
suffered from any heart or circulatory conditions? If yes, please give details
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Do you have any problems
with your back? If yes, please give details |
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Are you aware of any
previous accident or injury that may affect your yoga practice? |
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Yoga enquiries
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Do you have any previous
experience of yoga? If yes, please give a few details
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Are there any areas you
would particularly like to work on?
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Is there anything you
would like advice on?
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For female members –
would you like advice on practicing yoga during menstruation?
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Are you pregnant?
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Where did you hear about
the class? |
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Is there anything else
that you think may be useful for me to be aware of?
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I agree for my own safety and well being to
inform the teacher at the beginning of any
class should any changes in the information
given on this form occur, or if any medical,
physical or emotional problems should arise
during a class.
Signature
Please return the form to:
Sarah’s Yoga
Maple Leaf Cottage
Cleave Mill
Sticklepath
Okehampton
Devon
EX20 2NH
