WellWoman Yoga Health Form

About You

Name

First Last

Date of Birth

Address

Street Address City ZIP / Postal Code

Occupation*

Mobile Phone*

Email*

About Your Health

Do you have any of the following conditions?

Asthma
Allergies (please state details below)
Epilepsy
Heart Condition
Learning Disability
Physical Disablity
Other

If ‘Yes’ please expand:*

Have you suffered any injury or had surgery? (e.g. caesarean section, knee surgery) If so, please give details:

Have you experienced any of the following:

If Yes, please note how many and in which years:*

If you are a mother, please give the ages and genders of your children:

Have you experienced any medical probems related to your menstrual cycle?

Pre-menstrual tension
Endometriosis
Polycystic ovarian syndrome
Cervical dysplasia
Ovarian cysts
Breast cancer
Other

If Yes, please give details:*

Are you currently experiencing any of the following?

If you ticked any of the boxes above, please use this space to expand on the symptoms:*

Have you needed to seek treatment or take medication for any of the following conditions:

Anxierty/panic attacks
Depression
Extreme fatigue
ME
MS
Auto-immune disorders

If Yes, please expand:*

Have you practiced yoga before?*

Yes
No

If Yes, how frequently and for how long?*

Have you tried any complementary therapies?*

Yes
No

If Yes, please give details:*

Do you currently do any form of exercise?*

Yes
No

When / Where / What type?*

Are you currently in pain?*

Yes
No

If so, can you describe how you experience pain: where in your body, when, is the the pain accute or dull?*

How would you rate your pelvic floor tone?*

Very strong
Average
Weak
Very Weak

Is there any other information you think might be relevant to disclose to your Yoga Teacher?*

Is there any type of support that has been particularly helpful to you so far?*

What are your thoughts / feelings about attending this Yoga Class, Workshop or Yoga Break?*

What is your main objective to achieve with your Yoga Class, Workshop or Yoga Break?*

Are you taking any form of medication?*

If Yes please give details:*

Disclaimer

1. I understand that the Samye Centre will take all reasonable care to ensure that the yoga classes, workshops and weekends are safe. However, I agree that I will be engaging in physical activity and, as with all forms of exercise, there is the small possibility of injury occurring.
2. I assume these risks and take full responsibility for any possible injury sustained in a yoga class, workshop or weekend.
3. I have been advised to contact my doctor and/or consultant, before participating in Yoga Classes, Workshops or Weekends if I have any medical conditions that could affect my participation. I will inform my Yoga teacher should there be any change in my medical condition(s).
4. I understand that it may be necessary for the Yoga teacher to appropriately reposition me, to safeguard me from injury, and I consent to this.

Signed:*

Please type your initials to indicate your acknowledgement of the disclaimer and to confirm the submission of information submitted. All data is private and will NEVER be shared without your consent.

Contact Preferences

Samye Centre may wish to send you a reminder text at the start of each new block of classes, or in the week before a workshop or yoga weekend you have booked onto.*

If you have selected 'Yes', please ensure you have provided your mobile number at the top of this form.

How do you wish to be contacted if a class, workshop or yoga weekend has to be cancelled or changed at short notice?*

Please ensure you've included your correct contact details in the Contact Details section above!

Please notify me by text message.
Please call me on my contact number.
Please email me.

Would you like to be added to our mailing list, to receive occasional updates by newsletter and email? (Please select below)*

WellWoman Yoga Health Form

Women's Yoga - Health & Registration Form

About You

About Your Health

Disclaimer

Contact Preferences