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THE LITTLE YOGA COMPANY

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Participant Health Form

The following information is required for your safety. If you have any specific medical concerns or have an existing health condition, it is advisable to consult your GP or specialist before attending a yoga class.

Please complete this form before you attend a class, and resubmit it if your circumstances change.

If you have any queries please do get in touch.

First name*

Last name*

Email*

Phone*

Emergency contact name and phone number*

Are you currently pregnant or have you given birth in the last 6 months?*

Yes

N/A

Do you suffer from any of the following?*

Abdominal disorder or recent surgery

Arthritis

Unspecified back pain / problems

Spinal injury

Joint replacement

Hip problems

Shoulder problems

Neck problems

Heart disorders

High blood pressure

Low blood pressure

None of the above

Other

Are you currently experiencing any of the following?*

Unusual shortness of breath

Pain, pressure or tightness in the chest area

Unexpected pain in the abdomen. shoulders or arms

Severe dizzy spells or episodes of fainting

Regular lower leg pain

Unexplained palpitations or irregular heartbeats

None of the above

Do any of the following apply to you? If so, please provide details below

Have you had major surgery in the past 5 years?

Are you currently taking any prescribed medication?

Are you receiving treatment for any diagnosed medical conditions?

Please provide further information if you answered yes to any of the previous questions, or if there is anything else your teacher should be aware of

I can confirm that I have answered all questions honestly and that the information given is correct.

I confirm that I am not undertaking this activity against the advice of medical professionals.

I understand that yoga is a physical activity and I undertake this activity at my own risk.

Signature

Signature field is empty.

Date

Day

Month

Year

Safeguarding Policy

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