Your details
Name *
Your answer
Address line 1 *
Your answer
Address line 2
Your answer
City *
Your answer
Postcode *
Your answer
Phone number (ideally mobile) *
Your answer
email address *
Your answer
Date of birth
MM
/
DD
/
YYYY
Emergency contact (name and phone) *
Your answer
Lifestyle
How do you spend most of your time?
Your answer
How often do you...?
Never
Sometimes
Often
Always
Take exercise
Sleep well
Eat a balanced diet
Drink water
Drink coffee
Smoke
Drink alcohol
Have you practised yoga before? If yes, please tell me a little about your previous experience
Your answer
How often do you feel...?
Never
Somtimes
Often
Always
Happy
Energetic
Calm
Confident
Anxious
Tired
Health
Do you take any medications or supplements?
Your answer
Do you have any health problems relating to the following?
If yes please give detials
Your answer
Have you had any serious illnesses in the last 3 years? Please give detials
Your answer
Wishes
Why do you want to practice yoga?
Your answer
Are there any particular asanas (poses) or practices you are interested in learning or improving?
Your answer
Women only
Are you pregnant or trying to conceive? (for pregnancy please give details of how many weeks and any symptoms you have been experiencing)
Your answer
Have you had a baby in the last 3 years? Are you breastfeeding?
Your answer
Do you have any menstrual cycle related symptoms? (PMT, Menopause, Irregular periods?)
Your answer
Do you have an IUD for contraception?
Your answer
And finally
How did you hear about my yoga?
Your answer
Anything else you would like to share?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.