Confidential Health Form
Please complete this form to attend Iyengar Yoga classes at Zagyoga Iyengar Studio
Mobile or landline
Previous Yoga experience if you are not a regular student at Zagyoga Iyengar Studio
Date of birth
Please tick any that apply
Musculoskeletal Problems: Head, Neck, Shoulder, Arm, Elbow, Wrist, Hand, Back, Spine, Hip, Leg, Knee, Ankle, Foot, Other
Heart Related Illness
Eye or Ear problem
Chronic Fatigue, ME, Fibromyalgia
Arthritis (Osteo or Rheumatoid)
Pregnancy or recent birth
Asthma and other respiratory problems
Mental Health Issue
Any other conditions
Please add explanation and give relevant information regarding any of the above ticked boxes.
Please list all medications
Have you had any surgery in the last year
Please specify if the previous answer is Yes
Date of surgery
Name and Phone Number of Emergency Contact
I confirm that the above information is current and accurate. I consent to Zagyoga Iyengar Studio holding the above information for the purpose of maintaining a database and to help take into consideration any health issue for my safe practice of the yoga asanas and prananyamas. This information could also be shared with emergency services in the case of an emergency. I understand that this information will be processed in a manner that ensures appropriate security of my personal data, and this information will not be shared with a third party (other than emergency services). I understand that I can withdraw my consent at any time by contacting Zagyoga Iyengar Studio and my personal data would be erased and destroyed without delay. Once I cease to be a student of Zagyoga Iyengar Studio, I understand that my personal data will be erased/destroyed when requested.
Send me a copy of my responses.
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