Student questionnaire

YOUR PERSONAL DETAILS

Full name*

Gender*

Date of birth*

Address (including postcode)*

Country*

Telephone number (+ country code) - Mobile*

Email Address*

Emergency contact name and tel. no*

YOUR YOGA HISTORY / FITNESS LEVEL

Have you attended an Iyengar yoga class before?*

Yes
No

how long have you practiced Iyengar yoga?*

what style of yoga have you practiced and for how long?*

How did you hear about us?

Do you participate in any other physical activity, e.g. gym work, jogging, swimming, aerobics, badminton, cycling, walking or other?*

How regularly do you do this?*

What would you like to achieve by practicing yoga?*

YOUR HEALTH QUESTIONNAIRE

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.

Covid 19*

I have been formally diagnosed with the virus in the past
I am fully vaccinated against Covid 19
I am suffering with long term Covid effects (please list them at the end of this form)

These conditions require specific modifications to your yoga practice. If yes, please give details.*

Abdominal disorder or recent surgery - please give details*

Arthritis (osteo or rheumatoid) - please give details*

Back pain (if known cause please state) - please give details*

Knee problems - please give details*

Hip problems - please give details*

Shoulder or neck problems - please give details*

Heart disorders - please give details*

High blood pressure - please give details*

Low blood pressure - please give details*

ME / Chronic Fatigue - please give details*

Varicose veins - please give details*

These conditions may affect your practice and so provide useful information for your teacher

Are you /could you be, pregnant, or have you given birth in the last six weeks?

Yes
No

If you have answered yes to any of the above or if you had any recent operations (in the last two years) / any old injuries that still trouble you / any other medical conditions not covered above that might be adversely affected by yoga practice, If yes, please provide details.

ADDITIONAL NOTES

Iyengar yoga allows you to work at your own level to improve your flexibility, strength and general health. It is not competative and the postures can be adapted using props to assist in extension, and increase mobility. To avoid injury never force or strain yourself during the poses. Menstruating women should not do inverted poses, strong backbends or reverse standing poses. Pregnant women should be asked for specific advice. Those with special heath conditions should consult with their medical practitioner before performing any form of exercise / yoga classes. The teacher cannot be held responsible for any injury during the class, or any problem arising of a medical condition.

DECLARATION

I confirm the above information is correct. I know of no reason of why I should not participate in any form of activity or exercise suggested to me by XENOYOGA. I acknowledge that any suggestions from XENOYOGA are neither diagnostic nor prescriptive. 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 and advice XENOYOGA of any change in my medical information follow the advice given by my doctor. I have stated all my history regarding Covid 19 and i can confirm that i have been made aware to NOT join any class if i have any Covid or flue like symptoms.

Phone

This field is for validation purposes and should be left unchanged.

Student Health Questionnaire

YOUR PERSONAL DETAILS

YOUR YOGA HISTORY / FITNESS LEVEL

YOUR HEALTH QUESTIONNAIRE

ADDITIONAL NOTES

DECLARATION

xenoyoga_