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Health Questionnaire
A health questionnaire for attending Day Retreats and Workshops.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Name of event you are attending
*
Date of event
*
Who to contact in case of emergency - Name
*
Emergency contact - Telephone number
*
Emergency contact address
*
Have you practiced yoga before .. and if so what style?
*
Have you had a major injury in the last 5 years: Yes/ No
*
No
Yes
If you answered yes above, please give more details
Are you taking any prescribed medication: Yes/ No
*
No
Yes
If you answered yes above, please give more details
Are you receiving treatment for any diagnosed medical conditions: Yes/ No
*
No
Yes
If you answered yes above, please give more details
Have you had any recent operations: Yes/ No
*
No
Yes
If you answered yes above, please give more details
The following conditions require specific modifications to your yoga practice. Please indicate below whether or not you have any of the following medical conditions.
Abdominal disorder or recent surgery
Arthritis (osteo or rheumatoid)
Unspecified back pain/ problems
Spinal injury
Joint replacement
Knee problems
Hip problems
Shoulder problems
Neck problems
Heart disorders
High blood pressure
Low blood pressure
Please indicate if you ever experience any of the following symptoms.
Unusual shortness of breath with very light exertion
Pain, pressure, heaviness or tightness in the chest area
Unexplained pain in the abdomen, shoulders or arm
Severe dizzy spells or episodes of fainting
Regular lower leg pain during walking that is relieved by rest
Palpitations or irregular heartbeats
Are you currently pregnant or have you given birth in the last 6 months:
*
No
Yes
Any Dietary Requirements or Allergies? Please give details if so.
Are you vegan, vegetarian or pescatarian?
*
Vegan
Vegetarian
Pescatarian
None of the above
Are you happy to receive updates from ZenSpace Yoga about workshops and events via email?
Yes
No
I agree that I have read and understood the terms and conditions and health questionnaire and confirm that I have answered all questions honestly and that the information given is correct and I acknowledge that I exercise at my own risk.
*
I agree
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