Full Name

Email

Telephone Number

Address

Date of Birth

Do you suffer any respiratory issues?
YesNo
If yes, What respiratory issues do you have?

Do you suffer from chest pains, or any heart trouble?
YesNo
If yes, please give more details about your chest pain/heart issues.

Do you ever have spells of dizziness or feel faint?
YesNo
If yes, please state when you have felt dizzy or faint and state any relevant conditions.

Do you suffer from back pain or have any problems with joints?
YesNo
If yes, please state what back/joint pains you have.

Are you pregnant or have you recently given birth?
NoPregnantGiven Birth
If yes, please state how many weeks you have been pregnant or how many weeks it has been since you gave birth.

Please state any symptoms/conditions you are having as a result.

Are you recovering from a recent operation/illness?
YesNo
If yes, please give details.

Do you have any joint replacements and/or prosthetics?
YesNo
If yes, please state all.

Have you had either high or low blood pressure? (please tick all that apply)
HighLow
Do you have any recent injuries?
YesNo
If yes, please give details.

Do you have any allergies?
YesNo
If yes, Please state any allergies you have.

Please state any relevant conditions that may affect your practice that we should be aware of. (epilepsy, diabetes, severe migraines, etc)

If you suffer from any conditions, do you have your doctor’s approval to take exercise?
N/AYesNo

PLEASE NOTE: If you answered YES to any of questions, you are advised to seek medical advice/ approval before commencing an exercise class or consult further with your teacher.

I have been informed in writing that if I answer YES to any questions of this questionnaire, I should seek medical advice/approval before taking part in exercise classes. If I wish to continue without such advice I do so entirely at my own risk.

I hereby state that I have read, understood and answered honestly the questions on the PAR-Q. If my medical status changes I will need to inform the teacher. I understand that Yoga Me and any of its employees cannot be held responsible for any injuries or ill health arising from my participation in the exercise classes. Yoga Me teachers are committed to delivering safe classes ensuring correct technique is taught and learnt, I so still realise that in participating in these activities I may be at risk of injury. I hereby confirm that I am participating voluntarily.

I understand and confirm the above*

I declare the information I have provided is accurate and complete.*

Signature*