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First name
Last name
Email
Phone
Address
Emergency and GP Details
Emergency contact name
*
Relationship
*
Emergency contact phone
*
GP practice and name
*
GP phone
GP Address
*
Activity and Experience
Have you practiced any of the following before?”
*
Yoga general
Hot yoga
Reformer or Pilates yoga
Other sports movement
Other
How would you describe your current activity level?”
*
Very active
Moderately active
Lightly active
Mostly sendentary
Other
What are your main goals?”
*
Strengthening and toning
Flexibility and mobility
Stress relief /slerp
Injury rehab / pain management
Core & posture
Please add any details about your goals, injuries or areas of focus:”
Medical & Health Screening Please tick YES or NO and give details where requested. If you answer YES to any starred (*) questions, we may ask you to speak to your GP before attending certain classes, especially hot/warm and reformer sessions.
Has your doctor ever said you have a heart condition, or that you should only do physical activity recommended by a doctor?
*
Yes add brief details
No
Brief details
Do you ever experience chest pain, tightness, or pressure during exercise or at rest?
*
Yes brief details below
No
Brief details
. Do you ever feel faint, dizzy, or lose balance without clear reason?
*
Yes brief details
No
Brief details
*
. Do you ever feel faint, dizzy, or lose balance without clear reason?
*
Yes brief details
No
Brief details
Do you have high or low blood pressure?
*
Yes
Multi choice
Option 1
Option 2
Respiratory conditions (asthma, COPD, etc.)
*
Yes
No
more information Respiratory conditions (asthma, COPD, etc.)
Diabetes
*
Yes
No
If yes to • Diabetes
Major organ conditions
*
Yes
No
If yes to Major organ conditions
Epilepsy / seizures / neurological conditions
Yes
No
If yes Epilepsy / seizures / neurological conditions
*
• Mental health conditions relevant to relaxation or breathwork
*
Yes
No
Details if yes • Mental health conditions relevant to relaxation or breathwork
Do you have any current or recent injuries?
*
Yes
No
Do you have arthritis, joint hypermobility or joint instability?”
Yes
No
Do you have back or spine issues (disc, sciatica, scoliosis, surgery)?”
Yes
No
Do you have neck/shoulder problems?”
Yes
No
Do you have hip, knee, ankle or foot problems?”
Yes
No
Any fractures, operations or major surgeries in the last 12 months?
Yes
No
Have you been advised to avoid specific movements (deep twisting, backbends, weight-bearing on wrists, etc.)?”
Yes
No
Have you been diagnosed with osteoporosis or osteopenia?”
Yes
No
Do you have any of the following?” Options: • Autoimmune condition (e.g. RA, lupus) • Chronic fatigue / fibromyalgia • Persistent headaches / migraines • Balance or vision issues • Pelvic floor concerns / prolapse • Other – please specify
Single choice
*
Yes
No
If any of the above apply, please add details.
Are you currently pregnant?”
Yes
No
Have you given birth in the last 12 months?”
Pregnancy / postnatal details (if relevant)”
Are you currently taking medication that may affect exercise (e.g. beta-blockers, blood thinners, strong painkillers)?”
Yes
No
Details
Do you have any allergies, including to essential oils, latex, metals, or cleaning products?”
Yes
No
Allergy details”
– “Is there anything else we should know to keep you safe and comfortable in class?”
Reformer Yoga QuestionReformer Yoga – Additional Questions Fields: • Radio – “Have you used a Pilates or yoga reformer before?”
Yes
No
Short answe
Are you comfortable getting on and off a low or raised platform unassisted?”
Yes
No
Do you have difficulty lying on your back, front or side?”
Back
Front
Side
Do you have difficulty kneeling or weight-bearing on wrists/hands?”
Yes
No
Do you have a history of falls, balance issues or vertigo?”
Yes
No
Are you comfortable with gentle resistance from springs and with feet/hands in straps?”
Yes
No
Please give details of any YES answers for reformer work.”
Hot / Warm Yoga – Additional Questions Have you ever experienced heat stroke, heat exhaustion, or severe overheating?”
Yes
No
Have you been advised to avoid saunas, steam rooms or hot environments?”
Yes
No
Do you have uncontrolled high blood pressure, heart disease or a serious cardiovascular condition?”
Yes
No
Are you pregnant, trying to conceive or in early postnatal recovery?”
Yes
No
Do you get migraines or headaches triggered by heat, light or dehydration?”
Yes
No
Do you take medications that affect hydration or heat tolerance (e.g. diuretics)?”
Yes
No
If YES to any, please add details. You may be advised to attend non-heated classes.”
confirm that the information I have given is accurate and complete.”
Yes
No
“I understand the nature and risks of yoga and reformer sessions and agree to work within my limits.”
Yes
No
• “I understand the nature and risks of hot/warm yoga and will seek medical advice if needed.”
Yes
No
• “I consent to participate in classes at Village Rose Yoga under these terms.”
Yes
No
Do you consent to light, appropriate hands-on adjustments?”
Yes
No
Type your full name as your digital signature”
Type your full name as your digital signature”
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