Health Form | C And B Yoga

Cr

YOUR ACCOUNT

First Name*
Surname*
Email*
Telephone Number*
Address:*
Age Group:*
Emergency contact name / next of kin telephone number:*
Have you practised yoga before?*
- Yes
- No
If yes for how long?
Main reason you want to do yoga?*
What aspects of yoga interest you?*
- Physical Postures (asanas)
- Breathwork (pranayama)
- Meditation
- Relaxation
How did you hear about this course?*
Have you ever experienced any of the following?
Backache or pain?*
- Yes
- No
High Blood Pressure?*
- Yes
- No
Low Blood Pressure?*
- Yes
- No
Arthritis?*
- Yes
- No
Epilepsy?*
- Yes
- No
Heart Problems?*
- Yes
- No
Asthma?*
- Yes
- No
Depression*
- Yes
- No
Detached Retina /Other eye problems*
- Yes
- No
Dizziness or Fainting?*
- Yes
- No
Diabetes?*
- Yes
- No
Recent Operations?*
- Yes
- No
Recent Fractures / Sprains?*
- Yes
- No
Knee Problems?*
- Yes
- No
Neck problems?*
- Yes
- No
Recent Pregnancies?*
- Yes
- No
Are you pregnant?*
- Yes
- No
Any conditions that may affect your mobility or may cause you concern?*
- Yes
- No
If yes, please give more detail:
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TEL: 07393866507 Email: connie@candbyoga.com

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