Exit YOGA WAIVER Yoga agreement and medical questionnaire. Question Title * 1. Name Question Title * 2. Age Group Below 19 yrs old 20 to 25 yrs old 26 to 30 yr olds 31 to 35 yrs old 36 to 40 yrs old 41 to 45 yrs old 46 to 50 yrs old 51 to 55 yrs old 56 to 60 yrs old 60 + yrs old Question Title * 3. Email Address Question Title * 4. Would you like to added to my mailing list? Yes No Question Title * 5. What aspects of yoga most interests you? Physical posture (asana) Relaxation Meditation Healing and therapeutic benefits Breathwork Stress/anxiety relief Body awareness Strength Flexibility Posture and alignment Mental focus Sense of self care Other (please specify) Question Title * 6. Do any of these health conditions apply to you? (Please select if yes) High blood pressure Low blood pressure Arthiritis Epilepsy Heart problems Asthma Recent fractures or sprains Recent operations Back problems Neck problems Knee problems Recent pregnancy Depression Anxiety Other (please specify) Question Title * 7. Are you currently pregnant? Yes No Question Title * 8. Please let me know of any other conditions or recent injuries that will affect your mobility or are likely to cause you concern when practicing yoga. Question Title * 9. Please feel free to notify me of any physical, mental or emotional conditions that you think will optimise your experience in the session. Question Title * 10. I understand that yoga is a personal practice and it is important to listen to my body and respect its limits on any given day. If at any time during the class I feel discomfort or strain, I will gently come out of the posture. I agree to take full responsibility for my health, not exceeding my limits in the yoga class and for any injury or discomfort I might experience. I will inform my yoga teacher of any medical changes. I accept that neither Rosanne, nor the hosting facility is liable for any injury, or damages, to person or property, resulting from taking the class. I confirm that all the information above is correct to my knowledge. (Please sign 'I (name) agree and understand' ) Done