Yoga Consent Form With Victoria Rose Name * Client's Email Date of Birth Month Day Year Have you done yoga before? Yes No If yes, can you please provide more details? e.g. Style of Yoga, experience level. Do you have any physical disability or any health issues/conditions that I should be aware of? * Yes No If yes, please provide more details. Are you/could you be pregnant? Yes No Please select conditions you are experiencing or have experienced: Cough/cold High blood pressure Low blood pressure Chronic congestive heart failure Heart attack Varicose veins Stroke/CVA Pacemaker or similar device Heart disease Chronic cough Shortness of breath Bronchitis Asthma Emphysema Hepatitis Skin conditions TB HIV History of headaches History of migraines Vision problems Vision loss Ear problems Hearing loss Loss of sensation Diabetes Allergies/hypersensitivity Epilepsy Cancer Arthritis Gynecological conditions Lower back pain Upper back pain Shoulder pain Numbness to any part of the body Muscular pain Neck injury Seizures Knee surgeries If you answered YES to any of the above, please provide details below: Is there a chance you could be pregnant? * Yes No N/A Current medications and condition it treats: Are you currently receiving treatment/under investigation from another health care professional?: Recent surgeries: Relevant recent injuries: Do you have any other medical conditions? (eg. digestive conditions, hemophilia, osteoporosis, mental illness)? Do you have any internal pins, wires, artificial joints?: Consent Agreement Type your full name to confirm consent * By typing your name above, you confirm you have read and agree to this consent form. Date Signed * Month Day Year Submit
