Health Questionnaire

First name

Last name

Address + post code

Mobile number

Landline number (if you have one)

Email

Date of Birth

Occupation

Which class are you booking?

Mon 10am Pilates

Mon 6.15pm Yoga

Tue 6.15pm Pilates

Tue 7.35pm Yoga

Thu 10am Yoga

Thu 11.20am Pilates

Thu 6.15pm Pilates

Thu 7.35pm Restorative Yoga

Have you attended a Yoga and/or Pilates class before? If yes, for how long?

The following information is required to ensure your health. Whilst yoga and pilates may be practised safely by most people, there are certain conditions that require special attention. If you are unsure, please consult your GP before commencing class. Please indicate in the boxes below whether or not you have any of the following medical conditions and then provide further information.

Please provide any further relevant information

These conditions may affect your practice and so it will be useful for your teacher to be aware of them:

Please provide any further relevant information

Have you had any recent operations (in the last two years)?

Yes

No

If yes, please provide further information

Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by practicing yoga or pilates?

Yes

No

If yes, please provide further informaiton

Are there any movements or positions that you are unable to do?

Can you get up and down from the floor unaided?

Yes

No

Women: Are you, or could you be, pregnant or have you given birth in the last six weeks?

Yes

No

Do you practice any other physical activity, e.g. gym, running, swimming, cycling, walking or other? How regularly do you do this?

How did you hear about this class?

Can we contact you with relevant class info?

Yes

No

Is it ok if we add you to our mailing list (monthly newsletter from Inner Light Yoga & Health Co)? Please note that if you opt out of this you will not receive any information about classes, events etc.

Yes

No

Disclaimer - tick the box to confirm your understanding and acceptance of our disclaimer. See below.

I confirm my understanding and acceptance of this health questionnaire and its disclaimer

I agree to my details being retained by my teacher and understand that information may be released to a medical professional in the interest of delivering medical attention.

Statement of Responsibility:The information on this form enables me to work with you in the safest and most appropriate way, and to contact you about anything relating to our work together if I need to. Your details will be kept confidential. You are responsible for disclosing all relevant information and keeping me updated about any changes. We will be working mindfully to minimise the possibility of harm. However, please be aware that you are responsible for respecting your own limits and staying within them. Please tick to indicate that you have read and agree.

I agree

Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By submitting the questionnaire, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify your teacher of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes. Your teacher or the British Wheel of Yoga are qualified to express an opinion that you are fit to safely participate in any class. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. Where possible, your teacher may offer suitable modifications or adjustments and practices to suit different levels of experience and ability. Please always let the teacher know before the class if this is your first time practicing yoga or if you are not confident about your experience and/or ability. Where you are taking part in live-streamed classes, please note that the instructor may not be able to see you at all times. Where you have declared a health condition, please contact the teacher before the class if you would like to request that you are provided with suitable modifications or adjustments wherever possible. Please note, where you are taking part in a pre-recorded class, you will not be able to request specific adjustments or modifications. In all classes whether face to face, live streamed remote or pre-recorded remote, always follow your teacher’s safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class. This form is to be completed by yoga class participants for face to face and remote teaching. All information given will be treated in the strictest confidence and stored in accordance with General Data Protection legislation. Although there are tremendous benefits to overall health and wellbeing, yoga can be physically challenging. It carries with it risks that cannot entirely be eliminated. These include the risk of personal injury. The exacerbation of existing injuries or conditions. And also damage to property around you during your participation. Please note that although you may appear on video link during the live stream of the class, the instructor may not be able to see you clearly or instruct you individually as is possible in a face to face teaching scenario. If you need to amend your contact details, emergency contact information or have new health information that you wish to share with me so that I can take it into consideration when teaching you, please fill in this form. The Instructor cannot be held responsible for personal injury related to participation in a class if: • your doctor has on health grounds, advised you against such exercise • you fail to observe instructions on safety and technique • such injury is caused by the negligence of another participant in the class

I understand.

GDPR Statement - In order to comply with the General Data Protection Regulations, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work, and when you have given me permission to do so. To ensure that I only communicate with you in the manner of your preferred choice, please will you indicate below, your agreement, or otherwise, to the following means of communication:

Email

Phone

Date of completion of questionnaire & Signature

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