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Student Health Questionnaire

Have you had a major injury or operation in the last 5 years:

The following conditions require specific modifications to your yoga practice:

• Abdominal disorder or recent surgery
• Arthritis (osteo or rheumatoid)
• Unspecified back pain/ problems
• Spinal injury
• Joint replacement
• Knee problems
• Hip problems
• Shoulder problems
• Neck problems
• Heart disorders
• High blood pressure
• Low blood pressure

Please indicate if you ever experience any of the following symptoms:

• Unusual shortness of breath with very light exertion
• Pain, pressure, heaviness or tightness in the chest area
• Unexplained pain in the abdomen, shoulders or arm
• Severe dizzy spells or episodes of fainting
• Regular lower leg pain during walking that is relieved by rest
• Palpitations or irregular heartbeats

Are you currently pregnant or have you given birth in the last 6 months:
Do you have a doctor’s permission to participate in intense physical activities?

Thank you for submitting your form!

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