Waiver Form

FLYYoga: Health Questionnaire for New Students 

 

All information is strictly confidential. 

 

Name:________________________

E-mail: ____________________________________

Telephone:_____________________

Address: ______________________________________________________________

Postal Code: _________________

Age: ____

 

Have you done Yoga before? Yes/No 

 

If yes, what type(s) and for how long? 

 

What is your main reason for wanting to do Yoga? 

 

Which aspect(s) of Yoga most interest you?

□ Physical postures (Asanas) □ Breathwork (Pranayama) □ Relaxation □ Meditation □ Chanting & Healing □ Other aspects (please say which): 

 

Do any of these health conditions apply to you? (If yes, please give details): 

High blood pressure: Yes/No 

Low blood pressure/fainting: Yes/No 

Arthritis: Yes/No 

Diabetes: Yes/No 

Epilepsy: Yes/No 

Heart Problems: Yes/No 

Asthma: Yes/No 

Depression: Yes/No 

Detached retina/other eye problems: Yes/No 

Recent fractures/sprains: Yes/No 

Recent operations: Yes/No 

Back problems: Yes/No 

Knee problems: Yes/No 

Neck problems: Yes/No 

Recent pregnancies: Yes/No 

Are you pregnant?: Yes/No 

 

Emergency contact: __________________________

Emergency contact’s number:____________________


 

Waiver 

 

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day. (Initial here): _____

 

I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognize that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. I accept that neither the instructor, nor the hosting facility, is liable for any injury, or damages, to person or property, resulting from the taking of the class. Those under 18 years of age must have this form signed by a parent or guardian. (Initial here): _____

 

I take full responsibility for my health during the yoga classes (including any injuries). I will inform my yoga teacher of any medical changes. (Initial here): _____

 

I consent to video/audio recording of classes (confidential). (Initial here): _____

 

Name(Print):  :_____________Date:______________Signature:______________

Parent/Guardian:______________Date:_____________Signature:_____________

Fun-Loving FLYoga ©2020 by Jessica