Yoga for Healthy Backs: Client Questionnaire

Yoga for Healthy Backs:
Client Questionnaire

Thank you for your interest in my Yoga for Healthy Backs classes. I am excited to welcome you as a student.

Please complete the following questionnaire prior to attending your first class.

Providing this information will help me to best care for you and your back in the classes and enable me to provide you with modifications and guidance during the class that will best suit your individual needs.

All information you provide will be treated in the strictest confidence. Please review my Privacy Policy if you have any concerns.

Name

Email Address

Date of Birth

Next of Kin / Emercency Contact (name + telephone number)

Please tell me about your back. Include: any symptoms that you currently have and/or have had in the past, when and how your back pain started, what tends to aggravate and ease your pain, any diagnosis that you have been given, the results of any investigations (e.g. X-ray, MRI) and details of any spinal surgery you have had.

Is your back/neck pain (or any other joint problems you may have) worsened by exercise? Is your back/neck pain (or any other joint problems you may have) worsened by exercise? Yes No

Details

Have you had any joint replacements? Have you had any joint replacements? Yes No

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Do you have any heart conditions or chest pains (especially if they are exercise induced)? Do you have any heart conditions or chest pains (especially if they are exercise induced)? Yes No

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Do you have asthma or any other breathing difficulties? Do you have asthma or any other breathing difficulties? Yes No

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Do you have high or low blood pressure? Do you have high or low blood pressure? Yes No

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Do you have epilepsy? Do you have epilepsy? Yes No

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Do you ever feel faint or dizzy? Do you ever feel faint or dizzy? Yes No

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Do you have diabetes? Do you have diabetes? Yes No

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Do you have glaucoma? Do you have glaucoma? Yes No

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Do you suffer from depression or anxiety? Do you suffer from depression or anxiety? Yes No

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Do you suffer from a lack of energy? Do you suffer from a lack of energy? Yes No

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Do you have any other medical condition(s) requiring treatment? Do you have any other medical condition(s) requiring treatment? Yes No

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Do you take any medication? Do you take any medication? Yes No

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Are you able to stand unaided? Are you able to stand unaided? Yes No

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Are you able to get up and down from the floor unaided? Are you able to get up and down from the floor unaided? Yes No

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Are you able to lie on your back comfortably? Are you able to lie on your back comfortably? Yes No

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Are you able to position yourself on your hands and knees (on all fours) comfortably? Are you able to position yourself on your hands and knees (on all fours) comfortably? Yes No

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Are you able to lie on your front comfortably? Are you able to lie on your front comfortably? Yes No

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My general health is: My general health is: excellent good manageable challenging

Have you ever practiced yoga before? Have you ever practiced yoga before? Yes No

How often do you practice yoga? What styles of yoga do you normally practice?

Is there anything you would particularly like to gain from attending the yoga classes? If you have any specific movement/fitness goals, please let me know.

Is there anything else you would like to tell me about yourself, your back pain or your fitness activities/level?

Disclaimer: Disclaimer: I confirm that, to the best of my knowledge, I have answered the above questions accurately and I understand that it is my responsibility to advise the yoga tutor of any change in my medical information. I take full responsibility for my own health and wellbeing during the class and when I practice anything taught in the classes in another location. I agree to listen to my body and work within my own limits. If at any time I feel any pain or discomfort I will stop performing the activity and notify the yoga teacher. I understand that if I fail to do this my teacher cannot be held responsible for any injuries or accidents that may occur. I understand that it is my responsibility to check with my doctor if I have any concerns about my ability to participate in these yoga classes and to follow the advice given by my doctor and yoga teacher. I give consent to my yoga teacher holding and using my email address above for the sole purpose of informing me of future classes and related events. A secure permission-based email system (Mailchimp) will be used. I understand that my subscription preferences may be changed by me at any time. I understand that my yoga teacher is fully GDPR compliant and my information will not be used for any other purpose. To fulfil legal obligations, this data will be stored securely for 7 years from your last class.