Personal Health Questionnaire & Waiver Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY I give consent to be contacted by email by Sampoorna Yoga regarding my bookings and occasional updates. * Yes No How did you hear about Sampoorna Yoga? Google search Social media Through a friend Local flyer Other What are your primary goals in your yoga journey with Sampoorna Yoga? Please select the activities you have prior experience in: Yoga Meditation Dance Running Are there any other forms of exercise you engage in currently? Please select any current or past health conditions: Currently pregnant High blood pressure Low blood pressure Back/neck pain Knee pain Hip pain Anxiety/depression Glaucoma Low blood sugar Please list any other health concerns, injuries, allergies or medical conditions: Consent & waiver * In any physical activity, risk of serious physical injury is possible. Yoga and other activity is no substitute for medical diagnosis and/or treatment. The student assumes the risk of yoga or other activity and releases the teacher(s) and Divya Sharma from any liability claims. By ticking this box I agree and consent to participating in classes or workshops (either in person, private instruction, group instruction and, or on-line) with Divya Sharma at Sampoorna Yoga. I am aware of the physical risks involved with exercise and understand it is my personal responsibility to consult with my doctor regarding my participation. I have no medical conditions that I am aware of, which would prevent me from taking part in classes or workshops (either in person, private instruction, group instruction and, or on-line), and I assume responsibility for any risk or injury I may sustain as a result of my participation. I have read the above release and waiver of liability and understand its contents. I understand that it is my responsibility to find a pace that suits me. For on-line classes, I am aware that the teacher cannot monitor them in person, and I agree to be aware of my conditions and stop if I experience any issues or distress. I agree to the terms and conditions stated above. Thank you for submitting your personal health questionnaire & waiver form.
