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Student Health Questionnaire

Have you had a major injury or operation in the last 5 years:

The following conditions require specific modifications to your yoga practice:


• Abdominal disorder or recent surgery
• Arthritis (osteo or rheumatoid)
• Unspecified back pain/ problems
• Spinal injury
• Joint replacement
• Knee problems
• Hip problems
• Shoulder problems
• Neck problems
• Heart disorders
• High blood pressure
• Low blood pressure

Please indicate below if you ever experience any of the following symptoms:


• Unusual shortness of breath with very light exertion
• Pain, pressure, heaviness or tightness in the chest area
• Unexplained pain in the abdomen, shoulders or arm
• Severe dizzy spells or episodes of fainting
• Regular lower leg pain during walking that is relieved by rest
• Palpitations or irregular heartbeats

• Allergic reactions to essential oils

Are you currently pregnant or have you given birth in the last 6 months:
Has your doctor said it is okay for you to participate in physical activities such as Yoga & Pilates?
Have you practiced yoga, pilates, or other physical activities before?
How did you find me?

  • I can confirm that I have answered all questions honestly and that the information given is correct.

  • I acknowledge that the yoga recommendations, techniques, and ideas presented in this class do not serve as a substitute for professional medical advice.

  • I understand that any use of the information or techniques presented is at my own discretion and risk.

  • I have read and agree to the terms and conditions.

  • ​I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

  • I understand that personal information collected about me that can identify me, such as my name or where I live, will not be shared.

  • I understand that written client information shall be kept for as long as the client attends classes with Holistic Healing Arts. 

  • I understand that any original student intake forms may be digitised and stored securely (encrypted), permitting any printed originals to then be destroyed securely by means of shredding.

  • I understand that any authorised photos of myself, the student, will be retained and used indefinitely by the teacher, and remain the property of the teacher.

I am okay for my image to be used in marketing so that more people can see the benefits of yoga and mindfulness
If I provide a testimonial, I am okay if my name is used.

Thank you for sharing your information with me.

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