Yoga Health Awareness Form Yoga for Trauma Recovery

It is important that the workshop teacher is aware of any factors that may affect your practice. This will be kept strictly confidential and is to ensure that alternative practices or variations are given when appropriate. If you have any doubts we recommend you consult your GP or another qualified medical practitioner.

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Subject
Medical Form "Yoga for Trauma Recovery Workshop"

Emergency Contact Number (i.e. friend or family member):

Please indicate if you currently have or have had any of the following:

Heart condition YesNo

High or Low blood pressureYesNo

Spine or neck injury or condition YesNo

Diabetes YesNo

Epilepsy YesNo

Asthma YesNo

Bouts of dizziness YesNo

Hernia YesNo

Arthritis YesNo

Stroke YesNo

Depression YesNo

Anxiety YesNo

Panic attacks YesNo

Post-traumatic stress disorder YesNo

If ‘Yes’ to any of the above, please give details:

Any other medical conditions or anything else the teacher may need to know?

Have you had any surgery? If so, when and for what reason?

Are you taking any medication? If so then please name them, indicate what they are for and say for how long you have been taking them.

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

Have you practised yoga and meditation before? What kind and for how long?

Are you a yoga teacher or health professional?

Thank you very much for taking the time to fill in this form.

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