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Woodland Elements Dru Yoga
Healthy Back Programme - Registration Form
Thank you for completing this questionnaire so that I can understand more about your needs and how to help you move towards improved health with Dru Yoga.
About You
*
Indicates required field
Name
*
First
Last
Date of birth
*
Age
*
Phone Number
*
Mobile Phone Number
*
Email
*
Address
*
occupation
*
In case of emergency
name of gp or link worker
*
name of person to contact in an emergency
*
address / phone of GP/link worker
*
emergency contact phone number
*
I ask for these details and permission to contact these people ONLY in case of emergency. I will not use them for any other purpose.
Yoga Experience
Yoga Experience
*
Nil
Minimal
Regular classes
Experienced
How did you hear about this programme?
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What would you like to gain from participating in this healthy back programme?
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Medical History
Based on the diagram indicate any areas of pain, pins & needles or numbness.
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Please tick any of the boxes that apply to you and give more details in the box below
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Anxiety
Arthritis - osteoarthritis
Arthritis - rheumatoid
Asthma
Auto-immune disorder (inc ME/MS/Lupis)
Balance issues
Blood pressure - high
Blood pressure - low
Breathing problems
Cancer
Depression
Diabetes
Digestive disorders or abdominal issues
Epilepsy
Heart condition
Hiatus hernia
Hypermobility joint syndrom
Inguinal hernia
Joint problems - hip
Joint problems - knee
Joint problems - shoulder / neck
Long COVID
Migraine / headaches
Osteoporosis / osteopenia
Perimenopause / menopause
PTSD
Sensory disorder affecting eyes or ears
Spinal injury
Spinal disc hernia
Stenosis
Stroke
Thyroid issues
any other issues and further information
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Are you / have you recently been pregnant?
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Yes
No
Have you taken steroids for any length of time?
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Yes
No
What do you understand to be the problem with your back / neck?
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How Long have you been experiencing this?
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Have you ever been given a diagnosis about your back / neck pain?
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Yes
No
If yes, please expand. Who gave you this diagnosis and what did they say?
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Have you ever had any medical treatment, including physiotherapy/osteopathy/chiropractic for your back
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Yes
No
Are you currently receiving treatment
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Yes
No
List any movements that particularly trigger your symptoms?
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What eases your pain?
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Please list any medication you are taking and why
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Do you have any of the following symptoms due to your back condition?
Numbness, weakness or pins and needles in both legs
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Yes
No
Numbness in your inner thighs or around the genitals
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Yes
No
Unsteadiness on your feet
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Yes
No
Loss of control & feeling around your bladder/bowels
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Yes
No
Have you had any recent unexplained weight loss?
*
Yes
No
If you answered yes to any of these please give further details where possible.
*
In this programme you will be participating in movement in a variety of positions, all of which can be adapted for your comfort.
Are you able to get off and on the floor independently?
*
Yes
No
Are you able to lie on your front for 10 minutes?
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Yes
No
Are you able to lie on your back for 10 minutes?
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Yes
No
Are you able to be on all fours (kneeling)?
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Yes
No
Disclaimer
By submitting this questionnaire, you are confirming that the contents are true and accurate to the best of your knowledge. Please notify me of any changes to your responses in this health questionnaire before participating in future classes.
As a Dru Yoga and Shakti Dance teacher, I am not qualified to express an opinion as to whether you are fit to safely participate in any of my Dru Yoga or Shakti Dance classes. You must obtain professional or specialist advice from your doctor or health professional before participating if you are in any doubt.
Please always let me know before the class if this is your first-time practicing yoga or if you are not confident about your experience and/or ability. Where you are taking part in live-streamed classes, please note that I may not be able to see you at all times. Where you have declared a health condition, please contact me before the class if you would like to be provided with suitable modifications or adjustments. Please note, where you are taking part in a pre-recorded class, you will not be able to request specific adjustments or modifications.
In all classes whether face to face, live streamed remote or pre-recorded remote, always follow the safety instructions and listen to your body. Where a movement or class is beyond your experience or ability, feels too difficult for you, or you experience any discomfort, please do not continue the movement or class.
You accept liability for any injuries or harm you might sustain as a result of participating in live or pre-recorded yoga classes or workshops.
You also take full responsibility and liability for your own health and wellbeing during the class and when you practise anything taught in my live or pre-recorded yoga classes and workshops.
I confirm I have read the disclaimer
*
Yes
In order to comply with GDPR, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so and where you have given me permission to do so.
Please note all information collected on this registration form is treated as confidential and will not be shared with a third party. Data collected on this form is kept securely. Your data is kept for 7 years after your last session with me, as stipulated by my insurance company.
I agree to receiving newsletters from Woodland Elements, I understand I can opt out at any time
*
Yes
No
Submit
Home
Yoga
Book Now
Yoga Classes & Workshops
>
Watch Anytime
>
Dru Yoga Directory
Shakti Flow Directory
Journey through the Chakras
Customise Your Yoga
Yoga is for Everyone
>
Dru Yoga
Shakti Dance
Sound
Book Sound
Blog
About
Small Print
>
Privacy & Cookies
Safety
Terms and Conditions
Get in Touch
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