One to One Yoga with Helen
Please complete as fully as possible, to give me a good idea of how I can help you before we meet. Thank you!
Name *
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Email *
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Mobile *
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Sessions are in person in St Agnes, or online via Zoom video conference *
What would you like to schedule? *
What is your preferred day and time? *
Your answer
What age are you? *
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What is your main injury/ complaint, or primary focus for these sessions? *
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Tell me about the onset of your main complaint
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Is there anything you've noticed so far that helps it feel better, or makes it worse?
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What type of pain/ sensation is it?
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Where exactly do you feel it? You will show me when we meet but this can be useful to know in advance.
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What is the severity of the pain 1-10, 10 being the worst.
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Is there any particular time of day it feels worse?
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Do you have any other health concerns? *
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Do you sleep well? *
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Are your energy levels good? *
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Do you drink much water? *
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Do you take any medications? *
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What is your current exercise routine like? *
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What would be a realistic amount of time to dedicate to a home yoga practice? Eg. 30 minutes daily. *
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Tell me about your yoga experience *
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Do you or have you suffered with a heart condition? *
Do you feel pain in your chest during physical activity? *
Have you had chest pain in the last month when not doing physical activity? *
Do you ever lose consciousness or do you lose your balance because of dizziness? *
Do you have a joint or bone problem that may be made worse by a change in physical activity? *
Are you currently taking any prescription medication for blood pressure or heart condition? *
Are you pregnant? *
Do you have insulin dependant diabetes? *
Are you 69 years of age or older? *
Do you know of any other reason you should not exercise or increase your physical activity? *
How did you hear about me?
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Voucher code
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I hereby agree to indemnify and hold harmless H Clare from and against liability, damages, costs, loss or expense (including without limitation, legal fees) arising out of any bodily injury, at any time sustained by the undersigned. Yoga is no substitute for medical diagnosis and treatment; that yoga practice and/or specific poses are not recommended for individuals with certain conditions (e.g., cardiac illness, later stages of pregnancy, post-surgery); and that the student assumes the risk of yoga practice and releases the teacher and studio from any liability claims. *
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Payment Terms & Conditions: When we have agreed and scheduled an appointment, you will be invoiced for the full amount, which is to be paid on receipt to confirm your time slot. Appointments can be re-arranged or cancelled up to 24 hours in advance for no extra fee. After this time, all cancellations are non-refundable and re-scheduled appointments incur a 50% extra fee. *
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Signed *
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