Yoga Medical Concern Form
Please take a minute to fill in the following info. Required for all yoga classes and courses, in-person or online.*
First Name
Last Name
Date of birth
Email
Phone Number
Do you have a doctor’s permit to participate in physical activities?
Yes
No
Level of Physical Activity
Sedentary
Moderate activity
High activity
Hours of Sleep Per Night
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
Choose an Are you currently taking any medications?
Yes
No
If yes, please specify:
Choose your regular blood pressure:
High
Low
Normal
Do you have any spinal problems, such as herniated discs?
Yes
No
If yes, please specify:
Do you have any joint problems?
Yes
No
If yes, please specify:
Please specify anything we should know about:
Privacy Policy at Yoga 3D Shape School
I agree to the terms & conditions
Your Signature or Name and Last Name.
*
Clear
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