Health History Questionnaire

To be completed by yoga class participants for face to face and remote teaching. All information given will be treated in the strictest confidence and stored in accordance with General Data Protection legislation.

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Email

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Have you done yoga before?

If yes, how long have you practiced and what style?

Are you/could you be, pregnant, or have you given birth in the last six weeks?