Poppy Sayers Studio Questoinnaire and Terms of Use
1.
Name
2.
Email address
3.
Mobile Number
4.
Age Group
Under 18
18-24
25-34
35-44
45-54
55-64
65+
5.
Have you done yoga before?
Yes
No
6.
If YES, please provide further details (e.g. style, for how long, current practice)
7.
What is your main reason for coming to yoga sessions?
Exercise
Relaxation
Stress relief
Flexibility
Pain relief
Meditation
Spiritual
Other (please specify)
8.
The following information is required to ensure your safety. Whilst yoga may be practiced by the majority of people, there are certain conditions which require special attention. If you are unsure, please consult and seek permission from your GP before commencing yoga.
The following conditions may effect your yoga practice. Please tick if any of the following apply to you. If you tick any, please provide further details
below.
Abdominal disorders
Arthritis (osteo / rheumatoid)
Back pain/problems
Heart conditions / disorders
High blood pressure
Hip problems
Low blood pressure/fainting
Knee problems
Nerve damage / trauma
Osteoporosis
Pain, stiffness swelling
Pregnancy / recent pregnancies
Broken bones
Surgery (in the last two years)
Shoulder / neck problems
Auto-immune disorders (e.g. ME, MS)
Anxiety / stress / depression
Balance affecting disorder (e.g. vertigo Diabetes
Epilepsy
Sensory disorders affecting eyes / ears
Respiratory problems (e.g. asthma)
Other
Please provide further information
None of the above
9.
Do you have any other medical conditions not covered above that might be adversely
affected by yoga practice or are likely to cause you concern?
10.
DECLARATION
(Please read the following and sign below)
I confirm that the above information is correct.
I take full responsibility for my health during yoga classes
I understand that it is my responsibility to:
• Check with my GP beforehand if I have any concerns about my ability to practice yoga
• Advise the teacher of any change in my medical information or other, which may be relevant before the start of each class.
• Follow the advice given by my GP and yoga teacher but I understand that Poppy Sayers is a yoga teacher and not a medical professional of any type.
• Take full responsibility for not exceeding my physical limitations and for any injury that might occur as a result.
• Only do what feels comfortable in class and not to work in pain
• To inform the teacher if I experience any difficulty in class
• To practice mindfully and safely.
I acknowledge that participation in yoga classes exposes me to a possible risk of personal injury. I am fully aware of this risk and hereby release Poppy Sayers from any and all liability, negligence or other claims arising from or in any way connected with my participation in yoga classes in any location.
Yes
No
Please type your name and today's date below as your signature and acceptence of all above terms.