Yoga health questionnaire

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Infinite Harmony Health Questionnaire

Health form

• About you

• Name
  First Last
• Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Phone
• Email

• Yoga experience

• Have you done any yoga before?*
  • Yes
  • No
• If yes, which type and for how long?
• How did you find out about Infinite Harmony Yoga?
  • Facebook
  • Internet Search
  • Twitter
  • LinkedIn
  • Instagram
  • Yoga directory
  • Word of Mouth
  • Flyer
  • Basinga
• What is you main reason for doing Yoga?
• Which aspects of Yoga interest you?*
  • Physical postures (asanas)
  • Relaxation
  • Breathwork (pranayama)
  • Meditation

• Health information

• High blood pressure*
  YesNo
• Low blood pressure/fainting*
  YesNo
• Arthritis*
  YesNo
• Diabetes*
  YesNo
• Epilepsy*
  YesNo
• Heart Problems*
  YesNo
• Asthma*
  YesNo
• Depression*
  YesNo
• Detached retina/other eye problems*
  YesNo
• Neck/ Back/Knee problems*
  YesNo
• Recent operations*
  YesNo
• Recent fracture/sprains*
  YesNo
• Are you pregnant or had a child within the last 3 months?*
  YesNo
• Do you have any other conditions which affect your mobility and are likely to cause you concern when doing Yoga?*
  YesNo
• If you have answered Yes to any of the above then please provide full details here:*
• It is important that you consult with your General Practitioner if you are at all concerned about your physical or mental health. Please ensure that you inform your Infinite Harmony Yoga teacher of any medical changes.*
  • I agree

• Consent and sign off

• This information will be treated in the strictest confidence by your Infinite Harmony Yoga teacher. Please note that Yoga is done at your own risk. No responsibility can be accepted for any injury incurred whilst in an Infinite Harmony class.*
  • I agree
• Consent*
  I consent that the data collected in this form will be used to ensure that yoga postures are suitable for me. Data will also be used to contact me in case of a class cancellation or to give me class updates. From time to time I accept that I will also receive emails with class news and offers. Signing below confirms that I accept the above statements and that the information supplied has been freely given and is correct at the time of signing. I acknowledge that I can request to see all data held about me at any time. A full privacy policy can be found at http://infiniteharmony.co.uk/privacy-policy/
• It is not wise to try to do yoga under the influence of alcohol or drugs.*
  • I agree
• I take full responsibility for my health during the Yoga classes, including any injuries. I will leave my ego at the door and I will not push myself further than my body is able to go.*
  • I agree
• Date
  MM slash DD slash YYYY
• CAPTCHA

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