Health Questionnaire

Please read as by participating you are agreeing to the contents of the disclaimer.

You are responsible for your own health and wellbeing at all times and are recommended to communicate any queries or concerns with Olivia Reardon (yogaveta). The purpose of this questionnaire is to ensure Olivia is informed about how best to support you, when leading you in yoga. It is entirely up to you what information you disclose and you may leave any sections blank.

Please take care when filling in this questionnaire and check the contents are accurate before you submit it.

Any information provided will be used only for the purpose of yoga and stored safely.

Name

First Name

Last Name

Phone

(###)

###

####

Have you practised yoga before?

Yes

If you are pregnant, how many weeks?

Emergency contact name and relationship to you

Emergency contact telephone number

Please provide details of any major health problems you have had in the past or are currently managing.

This might include high or low blood pressure, recent surgery, epilepsy, diabetes, serious injury or accident, asthma, ulcers, hernias, arthritis; problems with your back, heart, knees, eyes, ears or mental health.

Please tick box below if you DO NOT wish to declare physical and/or mental health information.

It is your right to withhold information. We must inform you that if you do not disclose your health status, Olivia cannot give modifications or alternatives for physical conditions that have not been declared and will be unaware of anything that might cause emotional distress or otherwise exacerbate any mental health issues.

Hands on adjustments?

These assists are useful for alignment but only with your consent.

Yes please

No thank you

Please use the box below for any other information you would like to share with me.

How did you hear about me?

DISCLAIMER - PLEASE READ CAREFULLY: By submitting this form you are confirming the contents are true and accurate to the best of your knowledge and are indicating your understanding and acceptance of the following:

Participation is voluntary and at your own risk. Olivia is not qualified to express an opinion that you are fit to safely participate in any classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt. Where possible, Olivia may offer modifications, adjustments and practices to suit different levels of experience and ability. Where you are taking part in live or online events, Olivia may not be able to always see you. However you participate, follow Olivia's guidance and always listen to your body. If any practice is beyond your experience or ability, feels too difficult, or you experience any physical or emotional discomfort or pain, do not continue. Please wear appropriate clothing for the type of practice you will be doing and if practising at home, ensure the area you are in is free from hazards. Olivia will assume you have no existing health conditions or other information to declare, if, prior to taking part, you do not submit his questionnaire. Where you fail to submit the health questionnaire or declare a health issue to Olivia, Olivia will not be responsible should an issue arise as a result. Olivia has no liability for any risk or injury you may incur as a result of taking part in yoga. Please contact Olivia if your circumstances change or you have any concerns prior to taking part. Please sign to indicate that you understand. TYPE YOUR FULL NAME

Date

YYYY

GDPR Statement

Any information you provide in this form will only be held on file for the purpose of your tutor/event organiser carrying out their role and when you have given permission. In order to comply with General Data Protection Regulations, please indicate below if you agree that your contact details may be retained by your tutor/s to send you information they think may be useful to you, including events and relevant updates. Your data will not be shared with any third parties without your consent.

Yes