Health Questionnaire

Andrea Rimington Yoga - Health Questionnaire – Online Classes

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Regular physical activity and exercise has many benefits, however, some people should check with their GP before commencing a new activity or before returning to exercise following certain types of injury or illness. Please answer the following questions honestly by circling YES or NO as appropriate.

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1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor or as part of a medically supervised programme?

YES/NO

2.  Do you experience unexplained pain in your chest when you do physical activity or at rest?

YES/NO

3. Have you ever lost consciousness due or fallen due to dizziness?

YES/NO

4. Do you have any problems with your back?

YES/NO

5. Are you currently taking any prescribed medication for high blood pressure, a heart condition or other serious illness?

YES/NO

6.  Are you pregnant or have given birth in the last three months?

YES/NO

7.  Have you had surgery recently?

YES/NO

8.  Do you suffer from diabetes/asthma/epilepsy?

YES/NO

9.  Are there any other reasons not mentioned above, why you should only exercise in a medically supervised environment?

YES/NO

10.  Do you currently have any open wounds, sores, infectious skin diseases?

YES/NO

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If you have answered “YES” to any of the questions above, please give brief details including recommendations from health professionals (GP, Consultant, Midwife, Condition Specialist, Physiotherapist, etc.). I may require you to obtain doctor’s permission/ advice before undertaking classes. (please fill in more detail on back if needed)

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Online Class Notes

 (A) As with our studio classes, by taking part in any online class, you acknowledge that classes may be physically strenuous, and you voluntarily participate in them with full knowledge that there could be a risk of personal injury.

(B) When practising from home, you accept full responsibility for your space and the health and safety precautions within this space.

(C) You acknowledge that Andrea Rimington accepts no responsibility for any potential injuries as a result of practise outside of the studio space.

(D) Whilst practising online the student is responsible for choosing and taking suitable modifications within their practice and if a student chooses to divert from the general instructions of the class, then they are doing so at their own discretion.

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I have read and fully understand the Health Questionnaire. I confirm that, to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in the class. I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and if my health changes I should inform my instructor.

Client Name:

Client Signature:

Date: