Yoga Student Health Questionnaire

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For all yoga students who take yoga classes with Varsha Khatri

Full Name *

Address *

Email *

Would you like to sign up for Healthy Living with Varsha newsletters? *

Yes

Phone Number *

Emergency Contact Name *

Emergency Contact Number *

Have you had a major injury in the last 5 years? Yes/No. If Yes, please provide details *

The following conditions may require specific modifications at times to your yoga practice. Please indicate below whether or not you have any of the following medical conditions. Select all that apply

Recent surgey (within last 6 months)

Abdominal disorders

Back pain

Spinal injury

Joint pain

Knee problems

Hip problems

Shoudler problems

Neck problems

Heart disorders

High or low blood pressure

Joint, hip, or knee replacement

Other:

Are you comfortable with manual adjustments/physical corrections/hands on assistance during the yoga classes? *

Although Varsha will take all necessary precautions, no guarantee can be made in regards to exposure of covid-19.

Yes

Are you comfortable with doing any yoga poses off the mat? Ie wall exercises? *

This is to gauge interest. If at any point you are uncomfortable with wall exercises and we do them in class, a suitable alternative will be also taught.

Yes

Is there anything else that you would like to share with me or that I need to be made aware of.

Please re enter your name to state that you were as honest as possible with your answers. If you at any point decide to change your answer in regards to hands-on assistance, you must do so in writing. Also, please do advise me if your health changes in any way. *

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