STUDENT HEALTH QUESTIONNAIRE BRITISH WHEEL OF YOGA – RebeccaAllenYoga.co.uk

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.

Your name:

D.O.B if under 18.

Address:

Telephone contact number:

Land line:

Mobile:

Email:

Emergency contact name and telephone number:

Have you attended class before?

If yes, how long have you practiced yoga?

The following information is required to ensure your health. Whilst yoga 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 tick if you have any of the following medical conditions and then provide further information:

These conditions require specific modifications to your yoga practice:

Abdominal disorder or recent surgery

Arthritis (osteo or rheumatoid)

Unspecified back pain/ problems

Spinal injury

Joint replacement

Knee problems

Hip problems

Shoulder or neck problems

Heart disorders

High blood pressure

Low blood pressure

Other

Further information:

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

Asthma

Diabetes

Anxiety/depression

Auto-immune disorder (e.g. M.E., M.S., Lupus etc.)

Epilepsy

Balance affecting disorder

Respiratory issues

Migraine

Sensory disorder affecting eyes or ears

Glaucoma

Other (discuss with tutor)

Please say here if you do not wish to declare medical information.
Please be aware that your yoga teacher cannot give any modifications or alternatives that may be appropriate, for conditions that have not been declared.

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

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

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

Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, cycling, walking or other?

How regularly do you do this?

How did you hear about this class?

Disclaimer

Please read carefully; your submission of this form will be taken to indicate your understanding and acceptance of the following:

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.

Neither your teacher nor the British Wheel of Yoga are qualified to express an opinion that you are fit to safely participate in any British Wheel of Yoga organised sessions or any British Wheel of Yoga trained teacher’s yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt.

All of our yoga instructors are appropriately qualified or British Wheel of Yoga Accredited teachers, with high standards of teaching and best practice.  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.

Print your name here:

Sign or MARK WITH A CROSS here:

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

Date here:

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:  YES/NOPost:  YES/NOTelephone/text:  YES/NO