Back Care Course

All information supplied will be treated with the strictest confidence and stored in accordance with General Data Protection legislation.

Your name



Your email

Your address
Address
Your phone number

Emergency Contact Name

Emergency Contact Number

Have you attended a yoga class before?

If yes, how long have you practiced yoga, and what style have you practiced?

The following information is required to ensure your health. While most people may practice yoga safely, certain conditions require special attention. If you are unsure, please consult your GP before commencing class. Please indicate in the boxes below whether or not you have any of the following medical conditions and then provide further
information:

These conditions require specific modifications to your yoga practice:
Abdominal disorder or recent surgeryUnspecified back pain/ problemsJoint replacementHip problemsHeart disordersLow blood pressureArthritis (osteo or rheumatoid)Spinal injuryKnee problemsShoulder or neck problemsHigh blood pressureOther
Please write any further information if needbe here

These conditions may affect your practice, so it will be helpful for your tutor to be aware of them:
AsthmaAnxiety/depressionEpilepsyRespiratory issuesSensory disorder affecting eyes or earsDiabetesAuto-immune disorder (e.g., M.E., M.S., Lupus, etc.)Balance affecting disorderMigraineOther (discuss with the tutor)
Please write any further information if need be here

Please tick the following box if you do not wish to declare your medical information. (Please be aware that your yoga teacher cannot give any modifications or alternatives that may be appropriate for conditions that have not been declared.)I do not wish to declare any medical conditions

Have you had any recent operations (in the last two years)?


Do you have any old injuries that still trouble you? Or any other medical conditions not covered above that might be adversely affected by yoga practice?


Are you /could you be pregnant, or have you given birth in the last six weeks?


Do you participate in any other physical activity, e.g., gym, jogging, swimming, aerobics, cycling, walking, or other?

How regularly do you do this?

How did you hear about this class?

Disclaimer

Please read carefully; your submission of this form will be taken to indicate your understanding and acceptance of the following:
Please take care when filling in this questionnaire and check the contents are accurate before you submit it. By submitting the questionnaire, you confirm that the contents are true and accurate to the best of your knowledge. Please notify your teacher of any changes to your responses in this healthcare questionnaire before participating in classes subsequent to those changes.

Neither your teacher nor the British Wheel of Yoga is qualified to express an opinion that you can safely participate in any British Wheel of Yoga organized sessions or any British Wheel of Yoga trained teacher’s yoga classes. You must obtain professional or specialist advice from your doctor before participating if you are in any doubt.

All of our yoga instructors are appropriately qualified or British Wheel of Yoga Accredited teachers with high teaching and best practice standards. Where possible, your teacher may offer suitable modifications or adjustments and practices to suit different levels of experience and ability.

Please always let the teacher know before the class if this is your first time practicing yoga or if you are not confident about your experience or ability. Where you are taking part in live-streamed classes, please note that the instructor may not be able to see you at all times. Where you have declared a health condition, please contact the teacher before the class if you would like to request that you are given suitable modifications or adjustments wherever possible. Please note that when you are taking part in a pre-recorded class, you cannot request specific adjustments or modifications.

In all classes, whether face to face, live streamed remote, or pre-recorded remote, always follow your teacher’s safety instructions and listen to your body. If a movement or class is beyond your experience or ability, feels too difficult for you, or you experience discomfort, please do not continue the movement or class.

I confirm my understanding and acceptance of this health questionnaire and its disclaimer:
Yes

GDPR Statement

To comply with the General Data Protection Regulations, I must check whether or not you are happy for me to retain your contact details and send you information that I think may be useful to you, including training and events and relevant updates. I only hold information when it is necessary to do so in order for me to carry out my work and when you have permitted me to do so. To ensure that I only communicate with you in the manner of your preferred choice, please will you indicate below your agreement, or otherwise, to the following means of communication:

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