Wheelchair Adaptive Yoga Health Form

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Name: *

E-mail: *

General Medical History: (more specific spinal cord history questions below) *

high blood pressure

low blood pressure

headaches/migraines

cardiovascular disorders

depression

cancer

digestive disorders

psychosis

endocrinal disorders

anxiety or nervous disorders

reproductive disorders

drug dependency

respiratory ailments

arthritis

kidney disorders

chronic illness

recent surgery

epilepsy

dermatitis/eczema

diabetes

addictions

pregnanacy

None of the above

Other, please explain in next box...............

Required

Other medical conditions explanation.......

Please list any emergency medications

Please explain what condition you use a wheelchair for? If it's a spinal cord injury, please provide: level of injury, complete/incomplete? If incomplete, please describe particular sensations and movement abilities. *

Please briefly explain where you are at with balancing and transferring..... *

I am aware that with a spinal cord injury, you may be dealing with any or all of the following issues: bowel/bladder/pain/skin/spasm/sensitivity to touch or light etc, please briefly indicate and are there any other particular quirks with your body that may be relevant to know... understanding that we can adapt as we go along.

Are you currently active in any way? If so , what and how often *

Have you practised yoga before? If so, @ for how long and what style *

Have you practised pranayama (breathing exercises) and meditation before? If so, @ for how long and what style *

Would you like to be added on to my email database to keep up with my classes, specials and events *

Yes please!

No thanks

Emergency contact name and number please.... *

WAIVER STATEMENT: I understand that Jennie Jackson, cannot give medical advice and the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort I will listen to my body, adjust or change the posture, inform and seek assistance. I know that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I understand that yoga is not safe under certain medical conditions and take full responsibility for making the decision to practice yoga. I have been cleared by my medical team to take part in this adapted yoga class. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Jennie Jackson. *

I confirm I have read and accept this waiver statement by ticking this box!

Thank-you for registering - I'm excited and honoured to be guiding this wheelie yoga class series - it's going to be fantastic!

I will be in touch with you soon with a confirmation of registration

Namaste Jen :)

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