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Holistic Healing Arts

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Student Health Questionnaire

First name

Address

Last name

Phone

Date of Birth

Have you had a major injury or operation in the last 5 years: *

Yes

If “Yes” please give more details here:

The following conditions require specific modifications to your yoga practice:

• 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

Please indicate below whether or not you have any of the above medical conditions.

Please indicate below 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

• Allergic reactions to essential oils

Please indicate here whether or not you have any of the above medical conditions.

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

Yes

Has your doctor said it is okay for you to participate in physical activities such as Yoga & Pilates? *

Yes

What are you hoping to gain from your sessions with me?

Is there a particular type of holistic practice you are interested in such as pranayama, meditation, aromatherapy, or reiki? Or perhaps a style of yoga that you prefer or find interesting? If so, please share here:

Have you practiced yoga, pilates, or other physical activities before? *

Yes

If “Yes” please give more details here. What do you practice? Is it a regular practice? How do you practice self-care?:

Is there anything else you might like to share with me?

How did you find me?

Google

Social Media

Word of Mouth

Other

Student Declaration:

I can confirm that I have answered all questions honestly and that the information given is correct.
I acknowledge that the yoga recommendations, techniques, and ideas presented in this class do not serve as a substitute for professional medical advice.
I understand that any use of the information or techniques presented is at my own discretion and risk.
I have read and agree to the terms and conditions.
I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.
I understand that personal information collected about me that can identify me, such as my name or where I live, will not be shared.
I understand that written client information shall be kept for as long as the client attends classes with Holistic Healing Arts.
I understand that any original student intake forms may be digitised and stored securely (encrypted), permitting any printed originals to then be destroyed securely by means of shredding.
I understand that any authorised photos of myself, the student, will be retained and used indefinitely by the teacher, and remain the property of the teacher.

I am okay for my image to be used in marketing so that more people can see the benefits of yoga and mindfulness *

Yes

Your Signature

If I provide a testimonial, I am okay if my name is used. *

Yes

Thank you for sharing your information with me.

Join the Sangha

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How can I help you?:

By joining, you opt to receive the occasional update, discount, blog post and a FREE gift.

In yoga, the Sangha represents the community of practitioners who come together on the path of self-discovery and transformation. By joining our Sangha, you'll connect with like-minded individuals who share your passion for wellness, offering support, encouragement, and inspiration every step of the way.

Mandala chakra symbol for enegetic healing and wellness.

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This website, including its blogs, services, and products, provides information for educational and informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.