Health Screening Questionnaire

Your contact details

Full name

Title

Your email

Mobile

Date of birth

How did you hear about the class?
Word of mouthFacebookGoogleInstagramYogahub.co.ukPosterOther

Next of Kin details

Name

Relationship

Mobile

Landline

Health details

Are you pregnant or have you given birth in the last 6 months?
YesNo

Are you currently suffering from any injuries?
YesNo

If you have answered yes to the above, please provide information here:

Have you had any surgical procedures in the past 12 months?
YesNo

If you have answered yes to the above, please provide information here:

Do you have any medical conditions that could affect your practice ,e.g.
Asthma or breathing difficultiesHigh blood pressureLow blood pressure / faintingHeart problemsDiabetesMigraines, dizziness or blurred visionEpilepsyVertigo or other balance disorderFibromyalgiaOsteoporosis or osteopeniaOtherNo medical conditions

If you have any other medical conditions that may affect your practice, please provide information here:

Liability waiver

I’ve read and understood the questions and answered them accurately. I understand that The Health Architect cannot be held responsible for ill health or injuries arising from participation and that it is my responsibility to consult my GP if I have any concerns.