Name___________________________________________________
Address_________________________________________________
City_______________________State_____________Zip__________
Telephone (home)________________(business)________________
email
Yoga Teacher Training or other relevant
education:
The following information will
help your instructor to better support you in the workshop:
c Female c Male Age: _____
Describe your present state of health
Please check and clarify any of
the following conditions that apply to you:
c Allergies:
c Arthritis:
c Asthma:
c Chronic sinus condition:
c Diabetes:
c Endocrine conditions:
c Epilepsy:
c Glaucoma:
c Hernia:
c Hypoglycemia:
c Heart conditions:
c High blood pressure:
c Low blood pressure:
c Intestinal conditions:
c Osteoporosis:
c Recent injuries:
c Recent surgery:
c Spinal conditions:
c Ulcers:
c Urinary conditions:
WOMEN:
c Menstrual conditions:
c PMS symptoms:
c Pregnant:
c Hysterectomy:
c Menopause symptoms:
c Peri-menopause c Post-menopause
Describe any other
physical or mental conditions that would be helpful for your instructor to be
aware of. (Use back of page if
necessary.) List any medications you are taking and the conditions you are
taking them for.
I certify that the above
information is true and complete to the best of my knowledge and that I will
not hold Discovery Yoga Inc. or my instructor liable for any mishaps arising
from my participation in yoga class.
Signature_______________________________________________________Date_____________________