Name *

Name to be printed on the certificate

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

1. Do you have any shoulder or neck problems? *

Yes

No

2. Do you have any back or hip problems? *

Yes

No

3. Do you have any knee problems? *

Yes

No

4. Do you have RSI and/or Arthritis? *

Yes

No

5. Do you have high blood pressure? *

Yes

No

6. Do you have any other medical condition or injury? *

Yes

No

7. Are you on any medication? *

Yes

No

8. Are you currently seeing a physiotherapist or similar? *

Yes

No

9. Do you sleep well at night? *

Yes

No

10. Are you pregnant?

For women only

Yes

No

11. Do you have Endometriosis?

Yes

No

12. Are you experiencing any of the Negative effects of menopause?

Yes

No

13. If you have answered yes to any of the above, does your doctor know you are doing Yoga ?

Yes

No

15. How many days a week would you like to commit to Yoga? *

1

2

3

or more days