Yoga Atelier Registration
In order to provide as safe and supportive experience as possible I’d like to ask you some questions.
You're welcome to answer as many questions as you like.

All information is kept in the strictest confidence.

Feel free to share this form with friends, family, your therapist or doctor.

Sign in to Google to save your progress. Learn more
Name
Preferred  pronouns? 
Date of birth
MM
/
DD
/
YYYY
Mobile
Email
General health Backround
Do you have any physical injuries or pre-existing medical conditions? Please describe.
Have you ever had surgery? If yes, when and what kind?
Are there any movements/ yoga shapes which cause you physical discomfort or pain? Please describe.
Are there any body scan/relaxation/meditation/ breathing practices you would rather avoid? Please state which?
Do you suffer from back pain? If yes, please provide details.
Has your doctor ever said your blood pressure is too high (above 140 / 90) or low? Please specify.
Clear selection
Do you have a family history of heart problems, stroke, coronary disease?
Clear selection
Do you suffer from sleep issues? Either falling to sleep, or staying asleep?
Are you pregnant or post partum within the last 6 months?
Clear selection
I sometimes give physical "hands on" assists. Please let me know if you would rather have or not have these. (Due to Covid restrictions there are currently no physical assists, however please answer for future reference. )
Clear selection
Do you practice any other physical exercise on a regular basis? Please provide details.
Have you ever done yoga?
Clear selection
If yes, how long have you been practicing?
Please tick which of the following styles of mind body fitness techniques you have experienced.
Is there anything you particularly like about yoga/pilates/martial arts?
Is there anything you don’t like about yoga/pilates/martial arts?
Specifically, which of the following are you looking for?  Tick as many as appeal:
How did you hear about us?
Clear selection
YOUR CONSENT DECLARATION AND SIGNATURE PURSUANT TO THE PROVISIONS OF THE GDPR  ACT 2018 I confirm that I have read and understood this Privacy Notice and herby give my explicit consent to use and obtain my information (including information about my physical and/or mental health or condition as required) as described in this form. No liability is accepted for any independent actions taken or not taken because of information provided in this session. You must not rely on the information as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor, or other professional healthcare provider. If you think you may be suffering from any medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment. YOUR CONSENT DECLARATION AND SIGNATURE PURSUANT TO THE PROVISIONS OF THE GDPR  ACT 2018                    
Sign (please type your name in full to consent)
Date
MM
/
DD
/
YYYY
Emergency Contact Name:
Emergency Contact Phone

I am happy to be placed on the Whats App group and mailing list.  To contact me about sessions, events, offers or other information?
Clear selection
I am happy to have non identifiable pictures taken of me?
Clear selection
Is there anything else  there is anything else you would like me to know or worries you about coming to sessions?
Thank you for taking the time to fill out this form. Please email me if you have any other questions kathryn@yogaatelier.co.uk
Yoga Atelier .
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Yoga Atelier. Report Abuse
Google Forms