Questionnaire

For legal reasons this questionnaire has to be filled out. All information is strictly confidential and for professional use. The 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.

Full name *

Date of Birth

Email *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Occupation

Please state whether you sit, stand, pick up or carry weight, drive and/or use computers for long periods.

Have you ever practiced Ashtanga Vinyasa Yoga? *

If Yes, for how long and who was/were your teacher(s)?

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)RelaxationBreathwork (Pranayama)MeditationExploring ones-self and bodyPhilosophy

Are you currently on medication? *

If YES, Please describe

Are you affected by any of the following? *

Yoga can be practiced safely by most people. However, there are certain conditions which require special consideration in class.Heart problems of any typeAsthmaGlaucomaArthritis, bone or joint problemCarpal Tunnel SyndromNeck InjuryHigh blood pressureLow blood pressureDetached retinaHeadacheChronic painBack injuryKnee injuryOsteoporosisEpilepsyRecent fractures/sprainsNone

If YES. Please describe

Have you recently...? *

Received any type of bodywork (Physiotherapy, Osteopathy, Rolfing...)Had SurgeryNo

If YES, Please describe

Are you ...? *

PregnantHave given birth in the last 6 monthsTrying to concieveNone

Do 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 Montreux?

Declaration* *I 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.

Thank you for filling out this form.

HEALTH QUESTIONNAIRE & CONSENT FORM FOR NEW STUDENTS

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