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Health Questionnaire
Justine Rowan
2020-12-08T10:57:28+00:00
Health Questionnaire
Please complete the form below before coming to class
First Name
*
Last Name
*
Email
*
Phone Number
*
Emergency Contact
*
Age Group
*
Under 16
17-34
35-44
45-64
65+
Have you done yoga before?
Yes
No
Do any of these health conditions apply to you?
High blood pressure
Low blood pressure/fainting
Arthritis
Diabetes
Epilepsy
Heart problems
Asthma
Depression
Detached retina/other eye problems
Recent fractures/sprains
Recent operations
Back problems
Knee problems
Neck problems
Recent pregnancies
Currently pregnant
If you answered yes to any of the conditions above, please give details including how recent
Do you have any other conditions or injury which affect your mobility or are likely to cause you concern when doing yoga?
What physical activity do you currently do and how often?
What are your goals for coming to yoga?
How did you first hear about this class?
Confirm your responsibility
*
I take full responsibility for my health during the yoga classes. I will inform my yoga teacher of any medical changes.
Confirm information is correct
*
I confirm that all information provided above is correct and up to date to the best of my knowledge.
Subscribe to newsletter
I agree to receive class updates and newsletters from Rowan Yoga (your information will not be shared with any 3rd party entities).
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Data Privacy
*
I consent to my submitted data being collected and stored (read our
Privacy Policy
to find out more)*
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