Health and Lifestyle Questionnaire

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Have you practiced yoga before? *
This class is mostly, but not entirely, Chair-based and will involve some standing and lying down postures too. Do you have difficulty getting down and up from the floor? *
Please rate your current state of health *
Tick if any of the following apply to you: *
If you have ticked any of the above, I would suggest you inform your GP that you are starting a Yoga class. Please also let me know if any of the above conditions appear once the classes have started! Your health, safety and wellbeing is very important to me and Chair Yoga lends itself beautifully to modifications, props and alternatives if you need them.
Signed
Dated *
Dated
Data Protection Act
Information given on this form will be stored securely and in confidence and only used to inform me, as your Yoga teacher, about your health requirements so that I can plan my classes well. Thank You. Susanna Grace Jan2018