Health Questionairea Yoga Health Form All information will be treated in the strictest confidence Name * Email * Address * Phone Number * Health Conditions (all students) Please tick the check box if you are suffering from any of the following symptoms or conditions. Please give full details of the stage of pregnancy that you experienced them. Arthritis Athritis ArthritisT * Osteo-Arthritis Osteo-Arthritis Osteo-ArthritisT * Heart conditions Heart conditions Heart conditionsT * Allergies Allergies AllergiesT * Back pain/Sciatic pain Back pain/Sciatic pain Back pain/Sciatic painT * Osteoporosis Osteoporosis Osteoporosis * Stroke Stroke Stroke * Any spinal cord problems Any spinal cord problems Any spinal cord problems * Any joint problems Any joint problems Any joint problems * Diabetes Diabetes Diabetes * High Blood Pressure High Blood Pressure High Blood Pressure * Low Blood Pressure Low Blood Pressure Low Blood Pressure * Any Ulcers Any Ulcers Any Ulcers * Other Other Other * Female Students Did you have children, if yes how old are they Did you have children, if yes how old are they Did you have children, if yes how old are they * Is your menstrual cycle regular? Yes No Is your menstrual cycle regular? * Please give details Are you pregnant? Yes No Are you pregnant? * How many months/weeks? Have you suffered any injury or undergone any surgery (e.g. caesarean section, knee surgery, spinal cord) that may have some impact on your yoga practice? Are you taking any form of medication that may have some impact on your yoga practice? Have you studied yoga before? What do you hope to gain form this class? How did you learn about this class? Would you like to receive further information about yoga, related events or planned workshops via email? Yes No Thank you for completing this form reCAPTCHA Submit If you are human, leave this field blank.