Health & Registration Form

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Please complete and submit this form before attending a yoga class with Stacey. All information provided will be kept in the strictest confidence. You do not have to disclose anything that you do not wish to, but the information you give will help Stacey to meet your needs in the yoga class. If you have any concerns about a medical condition which may affect your ability to practice yoga then it is advisable to consult a healthcare professional before attending a class.

Email *

First Name (Name you wish to be known by) *

Last Name *

Mobile phone number (in case of urgent contact to advise of changes to classes) *

Have you done any Yoga before? *

No, Never

Yes, Currently

Yes, in the Past

If you have practiced yoga before, please let me know roughly how long and what style(s)

Please indicate if any of the following health conditions currently apply to you *

Anxiety/Stress

Depression

Back pain or injury

Neck/shoulder pain or injury

Arthritis/joint issues

Hypermobility

Asthma or other respiratory issues

Glaucoma or detached retina

High blood pressure

Low blood pressure

Chronic pain or fatigue

Epilepsy or seizures

Pregnancy

Other

Nothing to report

Required

If you have answered yes to any of the health conditions above, please provide any further information you would like to share, especially that which you consider relevant to your yoga practise. If you are pregnant, please indicate approximately how many weeks:

What are you hoping to get out of attending a yoga class?

How did you hear about Stacey Steele Yoga?

Web Search Engine

Facebook

Word of mouth

Noticeboard poster

Leaflet through door

Other:

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Stacey Steele Yoga would like to add your details to their mailing list in order to email updates and information about yoga classes and events.
*

I opt in to email updates

please do not add me to the email mailing list

I understand and agree that any information, instruction or advice obtained from any yoga teacher providing sessions for Stacey Steele Yoga should NOT be used as a substitute for advice or treatment given by a doctor or other healthcare professional. I take full responsibility for my own health and wellbeing during every class and when I later practise anything taught to me and agree that I participate in yoga at my own risk.
*

I agree

Required

The details given above are true to the best of my knowledge as at todays date:
*

YYYY

A copy of your responses will be emailed to the address you provided.

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