CLIENT INFORMATION FORM

The following information will enable your yoga instructor to offer you the safest and most appropriate yoga postures for your current level of health. All information given on this form will be treated as confidential.

    Health History:
    Please discuss any and all health concerns with your teacher and your doctor before practicing yoga.
    PLEASE TICK ANY OF THE FOLLOWING CONDITIONS THAT APPLY TO YOU.

    HYPOGLYCEMIAHEADACHESSKIN DISORDERSHEART ALIGNMENTPHILEBITISPMS SYNDROMEINFECTIOUS CONDITIONEPILEPSYPREGNANCYSLEEPLESSNESSFLU/COLD/FEVERCARPEL TUNNEL SYNCANCERT.M.J SYNDROMEVARICOSE VEINSCHRONIC/ACUTE PAINALLERGIESMENOPAUSENECK/SPINE INJURYDIGESTIVE PROBLEMSARTHRITISFIBROMYALGIAOSTEOPOROSISJOINT DISCOMFORTTHYROID CONDITIONDEPRESSIONDIZZINESSBACK PAINSCIATIC NERVE ISSUESHERNIATED DISCSHOULDER PAINHIP PROBLEMSDIABETES

    Please bring food or drink to class, if appropriate, in case of low blood sugar.

    Are you currently taking any medication or drugs?

    Agreement of Release and Waiver of Liability

    Please read the following carefully and sign below:

    • 1. I understand that the instructions given throughout the classes are intended as guidance only. I understand that while all due care will be taken by the instructor; they cannot be responsible for my improper practice at any time. To ensure that no personal injury occurs, I agree to adjust my practice according to my limitations and the decision to perform any yoga posture remains mine. I declare that I will take full responsibility for myself during the classes. I will notify my instructor before each class begins of any recent injury, illness, surgery or pregnancy.

    • 2. If I experience any discomfort during the yoga class I immediately notify the instructor. I understand that yoga should not be construed as a substitute for medical examination, diagnosis, or treatment and I should see a physician, or other qualified medical specialist for any mental or physical alignment. Because yoga should not be done under certain medical conditions, I have stated all my known medical conditions, and answered all questions honestly. I agree to keep my record updated with changes in my medical profile and understand there shall be no liability on the part of Raw Elements Healthy Lifestyle Yoga should I not do so.

    • 3. If participating in yoga classes, I recognize that yoga requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in yoga classes. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the classes.

    • 4. I knowingly, voluntarily and expressly waive any claim I may have against Raw Elements Healthy Lifestyle Yoga for injury or damages that I may sustain. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Raw Elements Healthy Lifestyle Yoga for any injury caused by negligence or other acts.

    Thank you for your time. We trust you will enjoy your experience with us RAW ELEMENTS

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    Created in 2003 Raw Elements is a holistic approach to mind body and soul. Individual or yoga group sessions bookings available, for Transference healings, Foot Ionic detoxes, Holisitic counselling, Corporate yoga and Personal sessions
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