Home
Classes
Workshops
Retreats
Contact Us
Gallery
Testimonials
Private Sessions
Yoga for Kids
5 Principles of Yoga
Retreat Booking Form
Health Questionnaire
More

Yoga Health Questionnaire

Please full out as much as possible and speak to me if you have any further questions.

Required fields are marked *

Your name *

Your e-mail *

Phone number *

Address

Emergency Contact (Name and number):

Previous Yoga experience and Yoga level:

Exercise sessions or hours per week:

Would you consider yourself:

Fit

Unfit

Do you suffer any health problems or under treatment with a Doctor:

Physiotherapy

Osteopathy

Chiropractic

Herbalist Supervision

Are you taking medication or Herbal remedies and if so what for:

Have you had any majoy accidents or injuries in the last 12 years? (please specifiy)

Have you had any operations in the last five years? (please specify)

Do you currently suffer from any of the below:

Insomnia

Anxiety

Depressions

Option 4

Mental-illness

Eating disorders

Hormonal Condition

Asthma

Diabetes

Allergies

Heart Conditions

High/low blood pressure

Back or Neck pain

Cancer

M.E.

H.I.V

Epilepsy

Migranies

Glaucoma

Dizzy Spells

Arthritis

Are you pregnant? (please specify number of weeks)

Dietary Requirements / Allergies

Vegan

Vegetarian

Lactose

Dairy

Wheat

Gluten

Nut Allergies

Any Further information you require me to know:

Declaration

I confirm that all of the above is correct to the best of my knowledge, and if anything changes to my health I shall inform Rachel Potter immediately

I confirm

By filling in this Yoga Health Questionnaire you confirm that all information given is correct to the best of your knowledge, and if anything changes to your health you shall inform Rachel Potter immediately

Karuna Yoga

If you would like to be updated on workshops, classes and retreats or have any questions relating to this site please do not hesitate to contact me and I will get back to you.

Rachel Potter

pottsyoga@hotmail.co.uk

07779 909 499

Please fill out a health questionnaire before you first visit:

Health Questionnaire

This website uses cookies to improve its functionality.

By using this site, you accept the use of cookies on your device.

Find out more Accept and Close