The London School of Yoga™

 

Assessment Form - Printable Version
Print and post this assessment form along with your cheque and booking form* to: 5 Child’s Way, London, NW11 6XU
please print in BLOCK CAPITALS:
name _____________________________________________________
date of birth
(dd/mm/yyyy)		 ___________     _____________     ______________  
email _____________________________________________________
occupation _____________________________________________________
sports / hobbies _____________________________________________________
  _____________________________________________________
Does your work /sport involve any of the following (tick those that apply):
  ______ driving ______ bending ______ standing
______ sitting for long periods
______ lifting heavy weights
______ any other repetitive action
 
1. Has your doctor ever said you have any sort of heart trouble? yes  /  no
2. Have you ever been told that you have arthritic joins or any bone or joint problem that may be made worse by excercise? yes  /  no
3. Have you had any operations in the last year? yes  /  no
If you have answered 'yes' to any of the above please give relevant details in confidence:
_________________________________________________________
_________________________________________________________
_________________________________________________________
4. Are you pregant, or have you had a baby in the last 6 months? yes  /  no
5. Do you suffer from backache? yes  /  no
If so, do you know why?
_________________________________________________________
_________________________________________________________
6. Is your blood pressure (circle one): high  /  low  /  normal
7. Are there any movements that cause you pain? (e.g.raising your arms, bending forward etc.)
_________________________________________________________
_________________________________________________________
8. Do you suffer from: epilepsy  /  asthma  /  diabetes
9. Have you been referred by a specialist practitioner? yes  /  no
10. Please give details of previous yoga experience:
_________________________________________________________
_________________________________________________________
_________________________________________________________
 

Disclaimer
The teacher can accept no liability for personal injury related to participation in a session if:

  • Your Doctor has, on health grounds, advised you against such excercise.
  • You fail to observe instructions on safety or techinque.
  • Such injury is caused by the negligence of another participant in the class.

Always consult your doctor if you are in any way concerned with your ability to perform yoga exercises

By submitting this form, you indicate that you have read the above and understand that you are responsible for your own safety during a yoga session.

 

* Don't forget to fill out the Booking Form as well.

 
© 2004 London School of Yoga™