JL & DLK YOGA HEALTH FORM

Health Form - Daren & Johanna Yoga

Please fill out form before you attend Daren Luke Kelly's or Johanna Lovisa Andersson's Yoga class. Details keeps strictly confidential.
Full Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile*
E-mail*
Next of kin*

First NameLast Name
Contact number
How did you find out about Daren's and Johanna's Yoga classes?
Other
Have you practiced yoga before? *
Please give details, what style of yoga etc.
Current Physical Activities?
Physically where would you say your strengths and weaknesses are?
What are you hoping to work on, achieve and/or discover doing the classes?
This could relate both to mind, body and spirit.
Please tick the appropriate column:

Have you broken or fractured any bones?Do you or have you had any spinal injuries/issues?Do you or have you had any muscular injuries/issues?Do you or have you had any joint injuries/issues?Is your blood pressure high?Is your blood pressure low?Have you had any illnesses or operations in the last year?Are you pregnant or trying to conceive?Are you currently on any medication?Do you have any allergies?Do you have any conditions or disabilities that may affect your ability to do Yoga? Eg Diabetes, Epilepsy, Vertigo, etc.
If you have ticked any ‘yes’ please give details here
Your conditions/injuries/medication, including when it arose, if it is current, how long ago it occurred etc.
TERM & CONDITIONS

IMPORTANT: If you are unsure as to whether you should attend a yoga class due to your medical status – please talk to your GP and seek permission.

I understand that I am responsible for monitoring my own responses during yoga and will inform the teacher of any changes in my health or if any details above change.

I understand that while all due care will be taken by the teacher, they cannot be held responsible for my improper practice at any time.

I understand that the instructions given throughout the classes are intended as guidance only. I declare that I will take full responsibility for myself during the classes.
I agree to Daren & Johanna Yoga terms & conditions*

Yes
Should be Empty:

Health Form - Daren & Johanna Yoga