Do any of these issues apply to you?
High blood pressure YesNo
Low blood pressure/fainting YesNo
Heart Conditions YesNo
Arthritis YesNo
Asthma/Respiratory Conditions YesNo
Diabetes YesNo
Epilepsy YesNo
Osteoporosis YesNo
Back pain/injury YesNo
Neck pain/injury YesNo
Knee pain/injury YesNo
Are you pregnant? YesNo
Due Date
Have you given birth in the last 6 months? YesNo
Birth Date
Have you had surgery in the last 6 months? YesNo
Date of surgery
I understand it is my responsibility to inform the yoga teacher of any changes to my health

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