Nature Space Yoga: Physical Activity Questionnaire
This questionnaire is kept strictly confidential and helps me work with participants to best suit their yoga practice.
Email address *
Participant Full Name *
Your answer
Have you experienced any of the following in the past 6 months *
Yes
No
A diagnosis of/treatment for heart disease/stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity?
A diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?
Dizziness or lightheadedness during physical activity?
Shortness of breath at rest?
Loss of consciousness/fainting for any reason?
Concussion?
Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active? *
Has a health care provider told you that you should avoid or modify certain types of physical activity? *
Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis,asthma, spinal cord injury) that may affect your ability to be physically active? *
If you answered "Yes" to any of the questions in the previous section, you should seek medical advice prior to starting any new exercise program, including yoga, to ensure it is appropriate for you. Is your doctor supportive of you participating in yoga? *
Questions/Comments?
Your answer
Waiver:
A copy of your responses will be emailed to the address you provided.
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