Yoga- Online Section

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Event : Webinar-Online
Date: Every Friday (Sep and Oct)
Time: 10:00 am to 11:00 am
Contact us at 0469 825 765 / 1300 439 455 or info@goodwillhealthcare.com.au
Website: www.goodwillhealthcare.com.au

Name *

Email *

Address *

Phone number

Date of Birth *

YYYY

satisfactory health checks

If the answer is yes to any of the questions on this form, please give full details in the space
provided of the dates, duration and outcome of the illness or condition. If we have any concerns
about your fitness for work, employment will be subject to satisfactory medical reports.

Have you practised yoga before? *

Yes

Are you are newcomer to physical activity? *

Yes

Have you any history of heart trouble? *

Yes

Have you suffered from any serious illness/surgery in the last 6 months? *

Yes

If yes – Outline briefly below.

Have you suffered from fracture? If yes – Outline briefly below

Do you regularly take medication? YES/NO please specify:

Do you suffer from any of the following? (if ʻyesʼ please give further details onany other comments section, page 2) *

Asthma

Arthritis

Breathing problems

Back pain

Knee pain

Bone or joint problems

Cancer

Chest pain

Poor eyesight

Diabetes

Dizziness

Multiple Sclerosis

Headaches

Epilepsy

Osteoporosis/Oste openia

Palpitations

Deafness

High/low Blood Pressure

pressure

Varicose veins

Required

If you have joint or back pain can you be specific about what and where and whataggravates it?

If there are any other conditions that may effect your participation please detail them below in thesection provided for any other comment.

Please say briefly why you are joining the class and what you are aiming to get outof a yoga class:

Any other comments:

With regards to all forms of exercise if you have any doubt about your level of health and fitness it is advisable to consult your GP prior to the commencement of any new fitness plan.The instructor must be informed of any injuries, handicaps or medical problems prior to joining the classes. The instructor cannot accept responsibility for personal injury whilst participating in a class if: a) You have been advised against exercise on the basis of a pre-existing health condition by your GP. b) You fail to observe the techniques & instructions given regarding safety.

I acknowledge that I exercise at my own risk. *

Date *

YYYY

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