Student Health FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastAge *Address inclusive of postcode *Mobile Number *Email *Emergency Contact Name & Telephone No *Have you ever practised yoga before, either at home or in a class *YesNoWhat other physical activity do you take part in (eg. gym work, jogging, swimming aerobics)? *Select any of these conditions if they apply to youAbdominal disorder or recent surgeryArthritis (osteo or rheumatoid)Back pain (if known please stateKnee, hip or pelvic problemsShoulder or neck problemsHeart disordersHigh or Low blood pressureAsthmaDiabetesAuto-immune disorder (e.g M.E M.S etc)EpilepsyAnxiety/depression/post-traumatic stressProblems with eyes, ears, vision or hearingBalance issuesAnything else you wish to inform us aboutIf you have anything else you wish to inform us about please do so hereDo you have past injuries that still trouble you? Or any other medical conditions not covered above that you feel your yoga teacher should know about? *YesNoIf yes please provide detailsAre you pregnant? *Yes (if yes we will contact you with another form to complete)NoHave you given birth within the last 12 months? *Yes (if yes we will contact you with another form to complete)NoSigned *I confirm that the above information is correct. I understand that it is my responsibility to:Check with my doctor if I have any difficulties or concerns about my ability to participate in the yoga class.Advise the yoga tutor of any changes in my physical and mental health. Follow the advice given by my doctor and/or yoga tutor.Date *Where did you hear about Cornwall Yoga Centre?Do you wish to join our mailing list and receive our newsletter containing info about new classes/workshops and events? *YesNoCommentSubmit
