Health Questionaire

Prior to attending your yoga class, or private yoga one to one, please fill out the details below and submit the form.

You can read my privacy policy here. If you have any queries on concerns, please contact me here.

Full Name
Date of Birth
Email
Phone Number
Emergency Contact Name & Number
Please give details of your yoga experience if any...
Do you participate in any other physical activity? Please give details....
Has your doctor advised you NOT to partake in any physical exercise or follow a nutritional plan, and that you should only do physical exercise and follow nutritional advice recommended by a doctor? (for example, a heart condition)?
Do you have carpal tunnel syndrome (wrist, finger, hand, forearm pain / numbness or tingling)?
Do you have high/low blood pressure?
Do you feel chest pain when you do physical activity?
Have you recently had chest pain while NOT doing physical activity?
Do you suffer from asthma, or breathing difficulties?
Do you loose your balance because of dizziness or have you ever lost consciousness?
Have you ever suffered from diabetes or epilepsy?
Have you had any recent major surgeries?
Are you/Is there a chance you could be pregnant? OR have you given birth in the past 6 weeks?
If you have ticked any of above Qs and need to give further information, please write in the box below.
Please give any details of any injuries (old or new) that may impact your yoga practice.
Please tick the box below to confirm that the information you have given in this form is accurate, and that you understand it is your responsibility to check with your doctor if you have any difficulties or concerns about your ability to participate in a yoga class. You are responsible for notifying me if any of this information changes.
Pre-booked classes must be paid for in advance. Bookings are subject to a 24 hour cancellation policy when either cancelling or rescheduling. Classes must be cancelled via email or phone and I will confirm receipt. Please tick the box to confirm you have read and understood this cancellation policy.
By submitting this form you confirm you have read and accepted the terms and conditions, including the cancellation policy and that you accept that Samantha Garstin is NOT liable for any injury, or damages, to person or property, resulting from the taking part in this yoga class.