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Yoga Health Questionnaire
Name:
  
Age:
  
Address or best contact details:
  


Previous yoga experience?

(please circle the description that best suits you)

Do you consider yourself:  

 fit    unfit    about average fitness

Do you suffer from any health problems
and if so what would that be?

  
Are you taking any medication
and if so what for?
  
Have you had any back or neck injuries?
  
Have you had any operations in the last 2 years and if so what was the operation for?
  
Have you ever had any serious accidents?
  
Have you ever suffered from the following?
  

High blood pressure
Heart condition
Glaucoma
Ear infections
Epilepsy
ME
Benign tumours
Cancer
Detached retina
AID’s
MS
  

For pregnant students only
If you are currently pregnant? How many weeks?
  
Have you suffered from any unexplained bleeding in pregnancy?
  
Are you experiencing any marked side-effects in your pregnancy?
i.e– nausea, fainting, dizzy spells, heartburn, fatigue? Other?
  
Are you experiencing any oedema or water retention?
  
Do you have any concerns with your pregnancy?
  

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