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Search for:
About
Ashtanga Yoga
Teachers
Schedule & Prices
Classes
Workshops
Rolfing® SI & Yoga
Gallery
Information
New to Yoga
Shala Etiquette
Practice Sheet
Invocation
Questionnaire
Contact
About
Ashtanga Yoga
Teachers
Schedule & Prices
Classes
Workshops
Rolfing® SI & Yoga
Gallery
Information
New to Yoga
Shala Etiquette
Practice Sheet
Invocation
Questionnaire
Contact
Questionnaire
delara
2018-10-08T13:37:09+02:00
HEALTH QUESTIONNAIRE & CONSENT FORM FOR NEW STUDENTS
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 Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
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)
Relaxation
Breathwork (Pranayama)
Meditation
Exploring ones-self and body
Philosophy
Are you currently on medication?
*
YES
NO
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 type
Asthma
Glaucoma
Arthritis, bone or joint problem
Carpal Tunnel Syndrom
Neck Injury
High blood pressure
Low blood pressure
Detached retina
Headache
Chronic pain
Back injury
Knee injury
Osteoporosis
Epilepsy
Recent fractures/sprains
None
If YES. Please describe
Have you recently...?
*
Received any type of bodywork (Physiotherapy, Osteopathy, Rolfing...)
Had Surgery
No
If YES, Please describe
Are you ...?
*
Pregnant
Have given birth in the last 6 months
Trying to concieve
None
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.
YES
NO
Thank you for filling out this form.
Verification
Please enter any two digits
*
Example: 12
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please leave it blank
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