Health Status Questionare - The Yoga Barre

Your name *

Email *

Phone

Address

Occupation

DOB

Person to Contact in Case of Emergency *

GP's Number

Medical History

Are you Pregnant?

Or how many weeks postnatal are you?

Do you or have you ever suffered from back/neck pain or injury?

Please indicate how many days a week you exercise:

What level of intensity?

Have you been treated/diagnosed for any of the following?

Have you been treated for another illness not outlined above? If yes, please specify.

Stipulate any surgical operations you have had

Are you on medication?

Yes

No

If yes, please explain

Tick box for consent

Please note: as with any exercise program, you must follow the instructions given. Failure to do so may result in an injury, in respect of which the course organiser will have no responsibility. The instructor has relied on the information supplied by you on this form. However, I do not profess to give medical advice and if you received advice not to exercise you must adhere to same. Under no circumstances continue with any exercise that causes you pain or discomfort, as the organiser will have no responsibility for the injury arising from same.

Yes, I consent

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Medical History

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