First Name
Last Name
Phone
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Email
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Address
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City
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Postal code
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Date of birth
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Occupation
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Heath Questions: Please tick where appropriate
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Allergies
Arthritis
Back pain / slipped discs
Blood Pressure (High)
Blood Pressure (Low)
Broken Bone/s (Tick if you have / had)
Cancer
Chest pain
Chronic Fatigue / Myalgic Encephalomyelitis
Diabetes Type 1
Diabetes Type 2
Depression
Digestive / intestinal issues
Dizziness / fainting
Eye Issues
Ear Issues
Long Covid
Headaches / Migraines
Heart Condition(s)
Joint Pain
Menstrual condition/pain
Multiple Sclerosis
Paralysis
Plantar Fasciitis
Pregnant (Tick if you are)
Skin diseases/rashes/ulcers
Stomach/intestinal problems
Varicose veins/ circulatory issues
Other health Issues, concerns, chronic illness Please specify in description box
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Any thing else you would like to share about your health?
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On a scale of 1-10, how physically active is your lifestyle currently (10 being the most active)?
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How did you hear about Prittie Yoga?
Internet search
Facebook
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Social Media
Real Networking
Word of mouth
Friend
Advert
Other
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Why are you taking a yoga class?
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Personal enjoyment
Relieve stress
Relaxation
To enhance the mind-body link
My doctor suggested yoga
Rehab and injury
Spiritual development
Increase flexibility
Increase strength
Breath awareness
Learn more about Energy Medicine Yoga
Other
What is your yoga background and how long have you been practising?
Health Conscent
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By reading and ticking the below box you are agreeing to take full responsibility for your voluntary participation in online / in person yoga classes. As far as I am aware my doctor has agreed it is safe for me to practice Yoga. I agree to be gentle and to work at my own capacity. I release the instructor from liability resulting from any injury or discomfort from my attendance and participation.
Permission
Yes, Emily can contact me by email and subscribe me to Prittie Yoga's newsletter. I understand that Emily will never share my email or contact details with anyone else.
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