Registration and Health Details

Registration & Health

To let me know about health issues and to register with Yinspire.

The information on this form is confidential to Yinspire

The information requested here may be more extensive than you are used to providing, however it is important for ensuring safety.

Please make sure you get the on screen confirmation after pressing submit - if you don't then I haven't received the form.

There is a save and continue option at the end of the page.

"*" indicates required fields

Name*

First Last

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Telephone*

Age*

Occupation*

If you are retired, please enter retired and former occupation

Emergency contact name and phone number*

Main reason for attending?*

How did you hear about Yinspire?*

Any previous yoga experience?*

Any previous yoga experience? If so please let me know the styles and how long ago.

Do you take part in exercise or sports regularly?*

Do you take part in exercise or sports regularly? If so please let me have some details.

How would you describe your health at present?*

How would you describe your health at present? Physical, mental or emotional.

How would you describe your energy at present?*

How would you describe your energy at present? Physical, mental and emotional?

Have you been pregnant, given birth or been breastfeeding in the last six months?*

Yes

Details about pregnancy/childbirth/breast feeding*

Have you been advised to limit exercise or physical activity, or otherwise consulted a medical practitioner about taking up yoga?*

Yes

Detail about medical advice received*

Do you have a recent history of Mental Health issues?*

Yes

Do you have a recent history of Mental Health issues?

It is unlikely anything will stop you practising with me, but I need this information for safety.

For example: Anxiety, Depression, Stress conditions, PTSD

Detail about mental health issues*

Please let me know if you carry a Crisis Card, or let me know if there are other steps to take in a Mental Health Emergency

Do you have any breathing issues?*

Yes

Do you have any breathing issues?

It is unlikely anything will stop you practising with me, but I need this information for safety.

For example: Asthma, COPD, Breath related trauma, anxiety or concerns.

Detail about breathing issues*

Do you have any physical health issues which may effect your yoga?*

Yes

Do you have any physical health issues which may effect your yoga?

It is unlikely anything will stop you practising with me, but I need this information for safety.

For example: Allergies, Arthritis, Back problems, Diabetes, Epilepsy or Neurological conditions, Eye Problems, Heart or Cardiac problems, High/Low blood pressure, Knee Problems, Neck Problems, Recent Fractures/sprains, Recent Operations, Other chronic or acute conditions

Please let me know if any of these conditions are medicated.

Detail about health issues*

Do you have any special emergency medical needs?*

Yes

For example, do you carry an Epi Pen, GTN Spray or Asthma Reliever. Is there anything I need to know in an emergency situation?

Detail about emergency medical needs*

Anything you would like me to know as your Yoga teacher?

Worries, concerns, family stuff, things on your mind. Its all confidential.

Any other comments, information, concerns or questions?

Would you Iike a copy of this form emailed to you for your records?

Yes please

Declaration

I take responsibility for my health during the yoga sessions. I will inform my Yoga Teacher of any changes to my health, and ask for assistance if needed.

I give consent for the information in this form to be stored confidentially in paper or electronic format, and to be contacted by email or SMS for class administration

Important - when you submit the form, you should get an immediate success notification on screen and an email notification - if you don't see these, then the form hasn't gone through - check all the entries are completed properly.

Date*

Comments

This field is for validation purposes and should be left unchanged.

Registration & Health

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Registration and Health Details

Registration & Health

Search the Site

Class Schedule

Winter 2023/24

Yoga for Well-being with Jessica

Yoga Therapy

Professional Yoga Therapy for

Recent Posts

Newsletter Sign Up

Socials and Feeds

Yoga for Well-being
with Jessica