Heath and Dietary

Health & Dietary Questionnaire

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

NameAddressEmail AddressTelephone numberDate of BirthOccupationGender

Yoga experience

Have you practiced 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:
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 pressureCirculatory 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, 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 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?
YesNoDo you have any old injuries that still trouble you?
YesNoIf you've answered "yes" to any of the above please give appropriate details, including approximate dates where relevant

Dietary Requirements

Do you have dietary restrictions or allergies? (Lactose intolerant, diabetic, hypoglycemic, nuts etc.
YesNoIf ‘yes’ please give further details:
Are you
VegetarianVeganIf you are a vegetarian do you eat fish?
YesNo

Other Information

Is there any other information that you feel you should tell us on order to be able to safely take in the retreat?

Disclaimer
I, being aware of my own health and physical condition and having knowledge that my participation in any yoga retreat may be injurious to my health, am voluntarily participating in the yoga retreat with Yoga with Zoe. Having such knowledge, I hereby release Yoga with Zoe from liability for accidental injury or illness, which I may incur as a result of participating in the said yoga retreat. I hereby assume all risks connected therewith and consent to participate in the said yoga retreat. I agree to disclose any physical limitations, disabilities, ailments or impairments, which may affect my ability to participate in the said yoga retreat.

I agree

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 Yoga Retreat. Yoga with Zoe cannot accept responsibility for personal injury whilst participating in the Yoga Retreat if:
a) You have been advised against exercise on the basis of a pre-existing health condition by your GP. b) You fail to observe the techniques & instructions given regarding safety.

I acknowledge that I exercise at my own risk.

Thank you! Your submission has been received!

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