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Health Questionnaire
Ebru Evrim Yoga Pilates
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Health Questionnaire
First Name
*
Last Name
*
E-Mail
*
Phone Number
*
Emergency Contact
Age Group
Under 16
17-34
35-44
45-64
65+
Have you done Yoga/Pilates before?
*
Yes
No
Which aspects of Yoga most interest you?
Please tick as many as you wish:
Physical postures (asanas)
Relaxation
Chanting & Healing
Breathwork (pranayama)
Meditation
Other (please specify):
Which aspects of Pilates most interest you?
Please tick as many as you wish:
Core strength
Increasing range of motion
Movement
Flexibility
Being subtle
Other (please specify):
Do any of these health conditions apply to you?
Please tick any that apply
High blood pressure
Low blood pressure/fainting
Arthritis
Diabetes
Epilepsy
Heart problems
Asthma
Depression
Detached retina/other eye problems
Recent fractures/sprains
Recent operations
Back problems
Knee problems
Neck problems
Recent pregnancies
Currently pregnant
If you answered yes to any of the conditions above, please give details
Do you have any other conditions, which affect your mobility or are likely to cause you concern when doing Yoga/Pilates?
If Yes, give details:
How did you first hear about this class?
Confirm your responsibility
*
I take full responsibility for my health during the yoga/pilates classes. I will inform my yoga/pilates teacher of any medical changes.
Confirm information is correct
*
I confirm that all information provided above is correct and up to date to the best of my knowledge
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