Health Questionnaire

1: Name *

2: Date of Birth *

3: Email *

4: Have you ever practiced Yoga before? *

5: Please tell us about your previous and current yoga experience (what style(s), for how long etc.) if you answered ‘yes’ to Q4

6: What other type(s) of exercise do you do?

7: Do any of these health conditions affect you? Whilst yoga may be practiced by the majority of people, there are certain conditions which require special attention. If you are unsure, please consult and seek permission from your GP before commencing yoga. *

Any type of heart condition High blood pressure Low blood pressure Glaucoma, detached retina, other eye issues Arthritis Diabetes Epilepsy Asthma Recent fractures/sprains Back injury Neck injury Knee injury Migraine/headaches Recent surgeries Recent pregnancies Pregnant None of the above and I am in good overall health

Do you have any other conditions which affect your mobility or are likely to cause you concern when doing yoga? *

8: I take full responsibility for my health during the yoga class, including any injuries. I will inform GreystonesYoga by email of any medical changes. If in doubt at any time, it is my sole responsibility to consult a medical practitioner and stop attending classes until I am satisfied that I am in good health and can participate in class safely. Please type in today’s date DD/MM/YYYY *

I consent to my submitted data being collected and stored *

Email address:

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email: info@greystonesyoga.ie

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