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HEALTH QUESTIONNAIRE

Please take the time to fill out this form, so that your teacher is aware of anything that could affect your yoga class.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

I confirm that I am not currently showing any of the following symptoms: a dry cough, a high temperature, loss of taste/smell

Thanks for submitting!

24 Rodney Road, Cheltenham, GL50 1JJ

England, United Kingdom

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