Soul Power Yoga | Power Vinyasa Yoga Studio | Yoga Classes Canberra

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First name *

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Surname *

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Contact Number *

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Male or Female *

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Date of Birth * Date of birth format: dd/mm/yyyy, example: 01/12/1985

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Date of birth format: dd/mm/yyyy, example: 01/12/1985

General Health Questionnaire. Please answer Yes or No. If Yes please explain

1) Have you ever had a heart attack, coronary revascularization surgery or a stroke? *

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No

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If Yes please explain

2) Has your doctor ever told you that you have heart trouble or vascular disease? *

Yes
No

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If Yes please explain

3) Has your doctor ever told you that you have a heart murmur? *

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No

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4) Do you ever suffer from pains in your chest, especially with exercise? *

Yes
No

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5) Do you experience swelling or accumulation of fluid about the ankles? *

Yes
No

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6) Do you ever get the feeling that your heart is suddenly beating faster, racing or skipping beats, either at rest or during exercise? *

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No

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If Yes please explain

7) Do you have chronic obstructive pulmonary disease, lung disease, or cystic fibrosis? *

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No

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8) Have you ever had an attack of shortness of breath that developed after you stopped exercising, at any time in the last 12 months? *

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No

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9) Have you ever been woken at night by an attack of shortness of breath, at any time in the last 12 months? *

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No

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10) Do you have diabetes (Type 1 or 2), and do you have trouble controlling your diabetes? *

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No

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11) Do you have any ulcerated wounds or cuts on your feet that do not seem to heal? *

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No

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12) Do you have any liver, kidney or thyroid disorders? *

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No

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13) Do you experience unusual fatigue or shortness of breath with usual activities? *

Yes
No

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14) If you have any other injuries, physical and medical conditions that may prevent you from undertaking an exercise, and you my have concerns of? *

Yes
No

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Soul Power Yoga reserves the right to ensure that you have answered the questions true fully.

Please consult your doctor prior to attending Soul Power Yoga studio, we expressly take no liability for injury, loss and or damage arising from the performance of Soul Power Yoga activities, including any advice or information provided by Soul Power Yoga.

Also be sure to let the teacher know before the beginning of each class

You have provided correct information and accept Soul Power Yoga terms and conditions