Health | Charlotte Evans Yoga - gentle yoga & relaxation

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Yoga on Demand
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Hello
About
Yoga on Demand
Free Offerings
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Health & Wellbeing Questionnaire

Name *

Address *

Email *

Mobile Phone *

Date of birth *

Do you experience any of the following? Please check all that apply

Heart condition

Respiratory problems

High blood pressure

Low blood pressure

Joint / bone / muscle injuries

Back problems

Arthritis

Dizziness / balance problems

Depression

Anxiety

Insomnia / sleep problems

Digestive issues

If you have ticked any of the above, please provide details:

Anything else you think I should know? i.e. have you had any recent illnesses, injuries, surgeries etc?

And finally anything else at all you would like to share with me - what you are looking for from yoga, if you have a particular favourite kind of yoga, whether you would like help with a particular problem... anything really!

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Health & Wellbeing Form

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