Health Questionnaire

Enter full name (required)

Enter your Email (required)

Enter your age (required)

Enter birth date

Enter your address (required)

Enter your phone number (required)

Enter your Occupation

Enter Emergency Contact

Have you ever had or do you have? if yes Checkboxes High blood pressureAny heart/stroke conditionAsthma/breathing difficultiesPain/tightness in chestMajor injuries/operationsPounding/palpitating heartBack painNeck/shoulder painRegular headachesArthritisBroken bonesknee/ankle problems

If yes to any above please describe in detail

you are not sure if you should do yoga/dance because of any health issues your doctor will be able to advise you

Are you pregnant? if yes tick the box
Yes I am
In the early stage of pregnancy it is not recommended to begin a yoga practice (After 12 weeks of pregnancy there will be modifications you can incorporate) Towards the end of your pregnancy it is also recommended to suspend your practice - Listening and connecting to your body will also tell you when to stop as it could be earlier for you

How did you find about Youtopia Wellness?

What do you want to get from practicing Yoga/Dance?

During the class listen to the instructions carefully and always let common sense prevail- Yoga is non-competitive

I have read and understood the foregoing and answered all the questions to my satisfaction and in consideration I hereby waive the right to all and any claims against the teacher for any injury or adverse change in my state of health arising directly or indirectly from my participation in classes
I accept and agree to all the terms

Enter date (required)
Enter date by using calendar on the right