Dev Yoga and Ayurveda

The following information is required for your safety. If you have any specific medical concerns or have an existing health condition it is best to consult with your GP before attending a yoga class.

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Name *

First

Last

Adress *

Adress Line 2

Postcode – City *

Telephone *

Email *

Date of birh *

Emergency Contact *

First

Last

Phone *

Email *

Relationship *

Have you practiced Yoga before *

• Yes
• No

Please give details about your Yoga Practice *

Are you taking any prescribed medication *

• Yes
• No
• Non prescribed

If “yes” or “non prescribed” please give more details here: *

If “yes” please give more details here *

Have you had a major injury in the last 5 years *

• Yes
• No

Please give more details in the box above.

Are you receiving treatment for any diagnosed medical conditions *

• Yes
• No

If “yes” please give more details here: *

Have you had any recent operations *

• Yes
• No

If “yes” please give more details here: *

Are you pregnant *

• Yes
• No
• I don’t know/ I could be

Have you given birth in the last 6 months *

• Yes
• No

The following conditions require specific modifications to your yoga practice. Please indicate below whether or not you have any of the following medical conditions. *

• Abdominal disorder or recent surgery
• Arthritis (osteo or rheumatoid)
• Unspecified back pain/ problems
• Spinal Injury
• Joint Replacement
• Knee Problems
• Hip Problems
• Shoulder Problems
• Neck Problems
• Heart Disorders
• Asthma
• Epilepsy
• Low Blood Pressure
• High Blood Pressure

If more than one answer is necessary, please give more details here: *

Please indicate if you ever experience any of the following symptoms: *

• Unusual shortness of breath with very light exertion
• Pain, pressure, heaviness or tightness in the chest area
• Unexplained pain in the abdomen, shoulders or arms
• Severe dizzy spells or episodes of fainting
• Regular lower leg pain during walking that is relieved by rest
• Palpitations or irregular heartbeat

If more than one answer is necessary, please give more details here: *

Client Declaration: I confirm that I have answered all the questions honestly and that the information given is correct. *

Please, write the date and your print name above.

Signature *

Please inform us if any of the above information changes.

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