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LoYoga Yoga Health Questionnaire

Health Questionnaire

All health information is used purely for the purpose of class management and insurance.
 
All contact details are used for the purpose of informing you of class dates or notice of cancellation and will be treated in the strictest confidence and stored in accordance with Data Protection legislation.  

No information is shared with any third parties.  

Your name and emergency contact details are recorded on a register that I bring to the classes you attend, and removed if you leave. 

Your Health Questionnaire is stored safely. I will keep it for the minimum amount of time that I am legally obliged to do so. After this time your form will be been destroyed. 

You may request to see the information I have on you at any time. 
1.Name:
2.Address:
3.Contact number:
4.Name and number of person to contact in case of emergency:
5.Have you attended a yoga class before?
6.Do you participate in any other physical activity, e.g. gym, jogging, swimming, aerobics, badminton, cycling, walking or other?
7.How did you hear about this class?
The following information is required to ensure your safety. Whilst yoga may be practiced safely by the majority of people, there are certain conditions which require special attention. If you are unsure please consult your GP before commencing class. Please tick the boxes below if you have any of the following medical conditions. Please give as much detail as possible.  
8.Please tick the boxes below if you have any of the following medical conditions:
9.These conditions may affect your practice, so please provide any useful information in order for me to best support you. 
10.Are you /could you be, pregnant, or have you given birth in the last six weeks?
11.Do you have any old injuries that still trouble you? If yes, please specify
12.Have you had any recent operations (in the last two years)?  If yes, please specify
PRIVACY POLICY 

Lorna (LoYoga) is committed to ensuring the privacy and confidentiality of your personal information, and to protect it from unauthorised access and disclosure. By completing and signing this form you agree to Lorna (LoYoga) holding this information about you. If you wish to know more about our privacy policy then please visit: http://loyoga.co.uk/privacy-policy/
Declaration

I confirm the above information is correct. I understand that it is my responsibility to :
 
~ Check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class.  

~ Advise the yoga tutor of any change in my medical information.
 
~ Follow the advice given by my doctor and/or yoga tutor.
13.Please Sign to confirm the above