Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Medical History *

Have you had a major injury in the last 5 years

Are you taking any prescribed medication

Are you receiving treatment for any diagnosed medical conditions

Have you had any recent operations

If “Yes” to any of the above please give more details here

None of the above

Medical Conditions *

The following conditions require specific modifications to your yoga practice. Please indicate below whether or not you have any of the following medical conditions.

Abdominal disorder or recent surgery

Arthritis (osteo or rheumatoid)

Unspecified back pain/ problems

Spinal injury

Joint replacement

Knee problems

Hip problems

Shoulder problems

Neck problems

Heart disorders

High blood pressure

Low blood pressure

None of the Above

*

Please indicate if you ever experience any of the following symptoms

Unusual shortness of breath with very light exertion

Pain, pressure, heaviness or tightness in the chest area

Unexplained pain in the abdomen, shoulders or arm

Severe dizzy spells or episodes of fainting

Regular lower leg pain during walking that is relieved by rest

Palpitations or irregular heartbeats

Are you currently pregnant or have you given birth in the last 6 months

None of the above

STUDENT DECLARATION *

I fully understand that yoga is a physical activity that may or may not cause physical injury. I agree to declare any health issue, conditions . For some conditions a physician's recommendation should be provided before the yoga class begins. In the event that poses might be uncomfortable, any suggested modification can be discussed to me directly in a respectful manner. If there's any strain or fatigue, I can come out of the pose to rest and understand that each and every one has its own physical limitations. I fully recognize that any injuries sustained from all the physical activities will be my responsibility. Therefore I release LVY of any liabilities.

YES I AGREE

ANY FURTHER INFO PLEASE USE TEXT SPACE ABOVE

Print Name *

First Name

Last Name

Todays Date *

MM

DD

YYYY