Declaration Form — Claire Best Yoga

FOR NEW STUDENTS

This declaration form is to be filled before you start class. All information given is highly confidential and for the teacher only. Please discuss with me if you are on any medication for diabetes, asthma or allergies and please bring it with you in class.

Name

First Name

Last Name

Emergency contact

Medical History- Operations/Medication

Please give information of any major operations you have received below. Are you on any medication right now? Are you currently receiving any treatment from the hospital/GP/professionals? Do you have any allergies?

Broken bones/Sprains

Have you ever broken any bones or have structural damage to the body? What treatment have you received?

Pregnancy

Are you pregnant?

Mental Health

Do you have any history of mental health illness, depression, anxiety?

Blood Pressure

Do you have high or low blood pressure? Vertigo or dizziness?

Diabetes

Are you diabetic? Insulin or diet controlled?

Lungs

Do you have asthma or any lung condition? Allergies? Nose bleeds?

Brain/Heart

Have you had a stroke? Epilepsy? Have you had a heart attack? Any other heart condition?

Cancer treatment

Are you undergoing treatment for cancer? Have you had treatment in the past?

Eyes/Ears

Do you have any eye disease? Detached retina? Tinnitus?

Energy/Immunity

Do you suffer with extreme tiredness? Have you received treatment for M.E? Do you have MS (Multiple sclerosis)?

Anything else you would like to say?