Health Form

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Privacy & Consent

Confidential health and yoga form

Before you commence your first yoga classes with me, or join a workshop or retreat, please fill in the health form. Any information given in the questionnaire will be confidential, equally you don't have to tell me about any conditions, but it would be helpful to ensure you practise safely. Any information given will be used in line with my Privacy Policy.

Please fill in the online form below. Thank you.

(NOTE: don't navigate away from the online form while filling in or the form will clear).

* Indicates required field

Name *

First

Last

Mobile Phone or Home Phone Number *

Email Address *

Age Group *

Have you practiced yoga before? *

Yes No

If so what type and for how long? *

Class you wish to attend (tick all that apply) *

5.30pm Monday Face to Face 7.30pm Monday Face to Face 10am Thursday Online 7.30pm Thursday Online Workshop / Retreat

Do you suffer from any pain or discomfort in any of the following body areas? *

Knee Hip Lower Back Other Back Neck Shoulder Ankle Other (e.g. recent operation)

Please give a few details *

Do you suffer from any of the following? *

Sciatica Rheumatoid Arthritis Osteoarthritis Vertigo High Blood Pressure Low Blood Pressure Heart Problems Migraine Stress Anxiety Depression Period Pains Epilepsy Hernia Asthma Diabetes Eye Problems Insomnia Other

Please give a few details *

Are you taking any medication? Please provide details *

Females - are you pregnant? (Please let me know if you become pregnant) *

Yes No

Generally how active are you? What other fitness activities do you participate in? What frequency? *

Briefly, what would you like to get out of these yoga classes or retreat/workshop? *

Where did you hear about my yoga classes/workshop/retreat? *

Privacy and Consent
Read my Privacy Policy

I give HesterYoga consent to -

1. contact me about classes, workshops, retreats and other relevant events (approx monthly email update and option to unsubscribe) *

Yes No

2. hold the personal information which I have provided in line with the Privacy Policy, I can withdraw at any time *

Yes No

Send

Please get in touch if you’d like any information about the classes, if you have a question or would like to give any feedback hi@hesteryoga.co.uk

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