Health Assessment Form Name* First Last Phone*Address* Street Address Address Line 2 City Email* Gender* Male Female Occupation Date of Birth* DD slash MM slash YYYY Emergency Contact* First Last Emergency Phone*How did you find out about our yoga classes?* Facebook Instagram Word of mouth Walking by Email Other Flyer If other, please describe how you found out about us. Have you had any of the following?* Diabetes Heart Disease / condition High / Low Blood Pressure Stroke Asthma Chest Pain Arthritis Epilepsy Osteoporosis High Cholesterol Migraines / Headaches Infectious Disease / Illness Cancer None Other If yes, please give details Are you pregnant?* Yes No If yes, when are you due? DD slash MM slash YYYY Any complications with current pregnancy? Any complications with previous pregnancies? Do you take any medications?* Yes No If yes, please describe the condition for which it is prescribedeg depression, anxiety, blood pressure, cancer, thyroid function etc. Have you ever Injured or currently have pain in any of the following areas of your body?* Head Neck Back Torso Shoulders Arms Hands/ Wrist/ Fingers Hips Upper Legs Knees Lower Legs Ankles/Feet None If so, what is the cause of the pain?Is there anything else that may affect you from participating in yoga classes? Is there any reason why you should obtain a medical clearance from your doctor?*If yes, please ask your doctor for a written medical clearance and provide it to Ballarat Iyengar Yoga. Yes No "I agree that I take all responsibility for my own injury that may happen, in the unlikely event that it does (notwithstanding all the care and skill that I acknowledge that the yoga studio will provide)".* I agree
