Health Questionnaire

Please fill out the following form to help us understand your physical condition.

Full Name

Email Address

Emergency Contact Name

Emergency Contact Number

Have you practiced yoga before?

Yes

Do any of the following health conditions apply to you? High Blood Pressure, Low Blood Pressure, Fainting, Arthritis, Diabetes, Epilepsy, Heart Problems, Asthma, Depression, Eye Problems, Recent Operation or Injury, Back Problems, Knee Problems, Neck Problems, Recent or Current Pregnancies

Yes

If you answered yes to the above question, please elaborate

I confirm that I take full responsibility for my health & that of any participants I book on behalf of, during the participation of any activity provided by Growth & Gratitude or any persons associated with the studio either online or in person. I confirm that all the information provided above is correct & up to date to the best of my knowledge. Should my health or contact details change I will inform my yoga teacher of these changes. I release any liability from any parties connected with Growth & Gratitude in the event of injury or illness. I agree to the privacy policy and the use of my data for marketing purposes only, and understand all medical information is for private use & not to diagnose. We will not share any medical information with any parties other than authorities where it is deemed absolute necessary to do so. View Privacy Policy

Signature

Today's Date

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