Student Questionnaire

To be filled in when joining yoga class

Please complete this before attending your yoga class,
Complete all fields to the best of your knowledge.

All information given will be treated in the strictest confidence and stored in accordance with Data Protection legislation.

Your name:

Telephone number / Mobile:

E-mail address:

Emergency contact name:

Emergency contact telephone number:

Have you attended a yoga class before?
YesNo

If yes, how long have you practiced yoga?
0-1 years1-2 years2-3 years3 or more years

If you answered yes above, what style?
AshtangaHathaVinyasaOther

How did you hear about this class?

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

How many times per week do you do this?

The following information is required to ensure your safety.
Whilst yoga may be practised safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class.

These conditions require specific modifications to your yoga practice;

  • abdominal disorder or recent surgery
  • arthritis (osteo or rheumatoid)
  • back pain (if known cause please state) 

  • knee or hip problems 

  • shoulder or neck problems 

  • heart disorders 

  • high or low blood pressure 


If any of the above applies to you, please give details:

These conditions may affect your practice and so provide useful information for your tutor.

  • asthma
  • diabetes
  • auto-immune disorder (e.g. M.E. M.S. Lupus etc)
  • epilepsy
  • anxiety/depression
  • sensory disorder affecting eyes or ears
  • other (to be discussed with tutor)

If any of the above applies to you, please give details;


Are you /could you be, pregnant?
YesNo

have you given birth in the last six weeks? 

YesNo

Do you have any old injuries that still trouble you?
YesNo

Any other 
medical conditions not covered above that might be adversely affected by yoga practice? If yes, please provide details.

Have you had any recent operations (in the last two years)? If yes, please advise what the operation was.

DECLARATION
Please tick this box if you do not wish to declare medical information

I confirm 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 change in my medical information
  • follow the advice given by my doctor and/or yoga tutor

Check this box to accept:

Date: