Birdsong Yoga Physio Health Questionnaire

Please complete the attached health screening questionnaire in order to be approved to join our online sessions.

Name

Age

Location

Contact Phone Number

Contact Email Address

Emergency Contact Name

Emergency Contact Number

Summary of cancer history (primary date and treatment, secondary dates, sites and treatment). Please be specific about sites of any bone metastases

Summary Info:

Any other illnesses or operations?

Current medications?

Reason(s) for coming to yoga?

Roughly how far can you walk at the moment? (either time or distance)

Can you get up and down from the floor?

GDPR consent:

You give Make 2nds Count permission to pass your information to Yvonne, Birdsong Yoga Physio for approval. Yvonne may contact you for further information.

You give Birdsong Yoga Physio permission to hold your questionnaire information, and weekly class notes on a one drive on a personal laptop.

You give permission for your mobile number to be added to a WhatsApp group/community once accepted to the yoga classes

Disclaimer:

By completing this health questionnaire, you are agreeing to participate in a Birdsong Yoga Physio class at your own risk, and to take responsibility for your health throughout. Do not work outside of your personal capabilities and stop if anything does not feel right. The instruction during class is to be taken as a guidance only and no participant should undertake a movement that causes pain. Birdsong Yoga Physio does not accept responsibility or liability that occurs during class.