QuestionnaireHealth Form HEALTH QUESTIONNAIRE & CONSENT FORM FOR NEW STUDENTSThe purpose of this questionnaire is to help your yoga teacher get to know you and your health better. This way the teacher can safely guide you through your practice and meet your needs.Name First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmergency Contact NameEmergency Contact PhoneOccupationHave you ever practiced Ashtanga Vinyasa Yoga?Have you done Yoga before? (if yes, what type(s) and for how long?What other forms of exercise do you do? For how long and how often?What is your main reason for wanting to do Yoga?What are your expectations and what would you like me to help you with?Which aspects of Yoga most interest you? (Please click as many as you wish) Physical postures (Asanas Breathwork (Pranayama) Exploring ones-self and body Relaxation Meditation PhilosophyAre you currently on medication?YesNoIf YES, Please describeAre you affected by any of the following? Heart problems of any type Glaucoma Carpal Tunnel Syndrome High blood pressure Detached retina Chronic pain Knee injury Epilepsy NoneYoga can be practiced safely by most people. However, there are certain conditions which require special consideration in class.Are you affected by any of the following? Asthma Arthritis, bone or joint problem Neck Injury Low blood pressure Headache Back injury Osteoporosis Recent fractures/sprainsIf YES, Please describeHave you recently...? Received any type of bodywork (Physiotherapy, Osteopathy, Rolfing...) Had Surgery NoIf YES, Please describeAre you ...? Pregnant Have given birth in the last 6 months Trying to concieve NoneDo you have any other conditions which affect your mobility or likely to cause you concern when doing yoga?How did you hear about Ashtanga Yoga Vevey?Declaration* *YesYesNoI take responsibility for my health during the yoga classes, including my injuries. I will inform my yoga teacher of any medical changes. Ashtanga Yoga Vevey does not take any responsibility for injuries from, or as a consequences of your participation in classes.CAPTCHA