Yoga Intake Form - ALLINSYNC with Anupa

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Name *First
Last

Age *

Gender

Contact No.

Emergency Contact Name

Emergency Contact Number

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had cheest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

If you've answered YES to any of the above questions, then you are required to gain consent from your doctor before participating in the exercise programme.  If you have answered  NO to all of the above questions and you have reasonable assurance of your suitability for:  An exercise programme will include exercises designed around your needs and goals.  The programme will work all components of physical fitness and use the principles of training.  You are advised to postpone entry into the programme if you feel unwell or have a temporary illness.  You must inform your instructor of any changes to your health status whilst engaged in your training programme.

Email *

I have answered all questions in this form honestly and I am aware that if I have answered YES to any of the questions I will need to consult with my GP before commencing in an exercise programme if I am affected by any of the questions in this form or at a later date I agree to inform my instructor in any changes on health and fitness.