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