Health Questionnaire

Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial Classes

This questionnaire has been designed to help you to enjoy your session safely. All information given will remain private and confidential.

NameAddressEmail AddressTelephone numberDate of BirthOccupationGenderPlease tick if you would like to be on the mailing list for workshops, retreats and classesYes please

Yoga and Aerial Yoga experience

Have you practiced Yoga or Aerial Yoga before?YesNoIf yes, please elaborate: for example, how much, how often, how long ago, what kind(s) of yoga have you done?
If no, what other type of exercise do you do?
Are you a newcomer to exercise?
YesNo

Medical Status

Have you needed to see a doctor or other health professional in the last 12 months
YesNoIf ‘yes’ please give further details:
Are you currently taking any prescribed medication?
YesNoIf ‘yes’ please give further details:
Have you any history of heart trouble?
YesNoIf ‘yes’ please give further details:
Have you suffered from any serious illness/surgery in the last 6 months?
YesNoIf ‘yes’ please give further details:
Are you suffering or have you in the last 5 years suffered from any of the following?
Back, neck or shoulder painHip or knees painOther pain or injury to any jointsHead-ache / migraineHigh blood pressure, hypertensionCirculatory disturbance, e.g. varicose veins, leg swelling, cold extremities, etc.Heart complaints: irregular beat, chest pain, etc.Breathing difficulties: breathlessness, cough, wheezing, pain on breathing, etc.Reduced bone density? e.g. Osteoporosis, osteopeniaDisturbance or changes in eyesight, Glaucoma, hearing; dizziness and balance problemsNumbness or tingling in the arms, legs or faceMuscular weakness; disturbance of balance or co-ordination; tremorAnxiety; depression; diagnosed psychiatric/psychologicalCancerDiabetesMultiple SclerosisEpilepsyM.EIf you have ticked any of the above, please give further details below:

Women

Have you had a baby in the last six months?
YesNo

(It is advisable not to resume any form of exercise for 12 weeks following the birth.)
NB: If you are pregnant or become pregnant please inform your instructor.

Are you experiencing any disturbance or changes in your menstrual cycle?
YesNoAre you Perimenopause, menopausal, postmenopausal?
YesNoIf you've answered "yes" to any of the above please give appropriate details, including approximate dates where relevant.

Past History

Have you EVER had any serious illness or medical condition that you have not already told us about?
YesNoHave you EVER had any surgery that you have not already told us about?
YesNoHave you EVER had any significant accident or injury that you have not already told us about?
YesNoFor our Day Retreats
Do you have any food allergies?
YesNoIf you've answered "yes" to food allergies please let me know what they are?

Other Information

Is there any other information that you feel you should tell us in order to be able to safely take part in your Day Retreat, Workshop, Yoga Classes, Trapeze and Aerial Classes?
I understand that private sessions, workshops, day retreat and classes are non-refundable and non-transferable.

Disclaimer
I, the undersigned, being aware of my own health and physical condition and having knowledge that my participation in any Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes may be injurious to my health, am voluntarily participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes with Yoga with Zoe.

Having such knowledge, I hereby release Zoe Lee (Yoga with Zoe) from any liability for accidental injury or illness, which I may incur because of participating in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I hereby assume all risks connected therewith and consent to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. I agree to disclose any physical limitations, disabilities, ailments or impairments, which may affect my ability to participate in the said Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes.

With regards to all forms of exercise if you have any doubt about your level of health and fitness it is advisable to consult your GP prior to the commencement of any new fitness plan. The instructor must be informed of any injuries, handicaps or medical problems prior to joining the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes. Zoe Lee (Yoga with Zoe) cannot accept responsibility for personal injury whilst participating in the Day Retreats, Workshops, Yoga Classes, Yoga Trapeze and Aerial classes if:
a) you have been advised against exercise based on a pre-existing health condition by your GP.
b) you fail to observe the techniques &instructions given regarding safety.

I agree, and I acknowledge that I exercise at my own risk

Yoga with Zoe COVID-19 Waiver Form

Addendum: Coronavirus/COVID-19
‍The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Yoga with Zoe has put in place preventive measures to reduce the spread of COVID-19. However, Yoga with Zoe cannot guarantee that you will not become infected with COVID-19.

Following government guidelines, we ask students not to attend classes if they are/or think they might be in breach of these (re: return travel, flu like systems, been in contact with someone that has COVID-19).

ASSUMPTION OF RISK: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur.

WAIVER OF LIABILITY: I hereby release, covenant not to sue, discharge, and hold harmless Yoga with Zoe, its employees, agents, and representatives, from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19.

‍Please read carefully; I hereby agree to the following: I agree and acknowledge that I am fully aware that participation in this activity may involve risks and I accept all the risks of participating. I will progress at my own pace and I understand my physical limitations, so I am sufficiently self-aware to stop physical activity before I become ill or injured. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Day Retreat, Yoga Holiday, Workshop, Yoga classes,Trapeze/Aerial Yoga classes. In consideration of being permitted to participate in the Day Retreat, Yoga Holiday, Workshop, Yoga classes, Trapeze/Aerial Yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against Yoga with Zoe for injuries or damages that I may sustain as a result in participating in the Day Retreat, Workshop, Yoga classes, Trapeze/Aerial Yoga classes.

My agreement acknowledges that I shall not now, or at any time in the future, bring any legal action against Yoga with Zoe, Zoe Lee, and/or any other person who may teach at Yoga with Zoe; and that this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns.

My agreement verifies that I am participating in yoga at Yoga with Zoe with my doctor’s full approval. If you are under 18, you must have a parent’s agreement. My agreement is binding to this liability waiver from this day forth.
‍

Name
Date
I agree

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.