Health Declaration

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

Age Group:

16 and under

17-34

35-44

45-64

65+

Have you practiced Yoga before? Yes / No. If Yes, please let us know more about your practice and style below.

What is your main reason for wanting to do Yoga?

What aspects of Yoga most interest you?

Physical Postures (Asana)

Breathwork / Pranayama

Meditation

Relaxation

Other

I agree the information herewith provide is to the full and best of my ability.

Do any of these health conditions apply to you? please tick

Abdominal Disorders

Back pain/problems

High Blood Preassure

Low Blood Preassure (fainting or dizziness)

Nerve damage / trauma pain

Shoulder / Neck problems

Knee Problems

Broken Bones / Stiffness / Swelling

Joint injury / Joint pains

Arthritis

Diabetes

Sensory Disorders affecting balance and coordination(Epilepsy, Eye Conditions, Vertigo, Ears)

Heart Condition

Respiratory problems (Asthma)

Depression / Anxiety / Mental Health

Pregnancy or pre or post natal

None

If you ticked any of the above or unble to find your concerns or conditions listed above, please provide further information below if you think this may affect your mobility or cause you concern when doing Yoga?

I agree the information herewith provide is to the full and best of my ability.

Date

Full Name

Thanks for submitting!

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