Request edit access
Aerial Yoga - Health Questionnaire 
Please read all the questions and answer to the best of your ability.

All information is kept strictly confidential and will only be shared with your instructor prior to attending the session. 
Sign in to Google to save your progress. Learn more
Full Name  *
Date of Birth  *
Mobile Number  *
Email  *
Emergency Contact - Name & Number  *
Do you suffer with Low/High Blood Pressure? 

If yes please give further details. 
 *
Do you suffer with any heart conditions?

If yes please give further details. 
 *
Are you currently pregnant? Or had a baby within the last 12 months? *
Have you had any type surgery within the last year? 
Please consider broken bones or any physical conditions that could affect your ability to exercise.

If yes please give further details. 
 *
Please expand on the above question if answered yes.

Eg. What type of surgery & when did the surgery take place?
Do you suffer from or previously suffered from Glaucoma? *
Do you currently suffer with any other eye issues?

If yes please give further details. 
 *
Do you suffer with Vertigo? *
Do you suffer with Carpal Tunnel Syndrome? *
Do you currently suffer from any wrist, elbow or shoulder injuries?

If yes please give further details. 
 *
Do you currently suffer from Osteoporosis? 

If yes please give further details. 
 *
Do you have a tendency to Fainting?

If yes please give further details. 
 *
Have you ever suffered from a Stroke?

If yes please give further details. 
 *
Are you currently taking any medication or treatment? 
If yes please inform us of what type of medication. 

(Please consider weight loss medication as this can affect your ability to exercise) 
 *
I believe I have answered all these questions to the best of my ability and will inform my instructor if anything changes. I understand that I partake in any physical activity at my own risk. *
How  did you hear about us?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms