Welcome To Quiet Flow Yoga

Confidential Health Questionnaire and Registration Form

Welcome to Quiet Flow Yoga

To ensure your safety and tailor our classes to your needs, please complete this confidential health questionnaire honestly and fully. Your information will be kept securely and used in accordance with our Privacy Policy.

All information provided remains confidential between you and your instructor.

Participant Details

Full Name

Date of Birth

Phone

Emergency Contact Information

In the unlikely event of an emergency during a class, please provide the details of a contact person who is NOT attending the class with you today.

Emergency Contact Name

Emergency Contact Number

Relationship to You

Health Screening Checklist

Please tick any condition you currently have, have had in the past, or for which you are currently receiving treatment.

Cardiovascular & Respiratory Health

High or low blood pressure

Heart conditions (e.g., angina, history of heart attack, pacemaker)

Asthma or other breathing difficulties

History of dizziness or fainting

Musculoskeletal & Joint Health

Back pain or chronic pain

Neck pain

Joint problems (e.g., arthritis, knee issues, shoulder injuries)

History of recent surgery (within the last 6 months)

Osteoporosis or osteopenia

Hernia or slipped discs

Other Conditions

Are you pregnant or postnatal? (If yes, how many weeks/months?)

Diabetes (Type 1 or 2)

Epilepsy or history of seizures

Recent injuries, sprains, or fractures

Any mental health conditions that may affect your practice (e.g., severe anxiety, PTSD)

Any other medical condition not listed above that the instructor should be aware of?

Details & Additional Information

Please provide brief details on any conditions checked above, and let us know if there are specific poses or activities you should avoid based on medical advice.

Condition/Area

Condition Name

Medications

Goals/Concerns

Waiver and Declaration

Please read carefully before signing.

I confirm that the information provided above is accurate to the best of my knowledge.
I understand that it is my responsibility to inform the instructor immediately of any changes to my health or physical condition before each class.
I understand that yoga requires physical exertion and that I am participating voluntarily. I am aware of the risks involved and agree to practice within my own limits.
I have read, understood, and agree to the Terms and Conditions and Health Waiver provided by Quiet Flow Yoga.
I provide explicit consent for the instructor to process my special category (health) data solely for the purpose of ensuring my safety during yoga classes, as detailed in the Privacy Policy.
In the event of an emergency, I consent to emergency medical care providers being contacted using the information I have provided.

Signature

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Printed Name

Date

Thank you for completing this form. Please hand this to your instructor before the class begins.