Enrolment Form — IYISL

470 New Cross Road

London, England, SE14 6TJ

020 8694 0155

A dedicated space for Iyengar yoga

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Enrolment Form and Medical Questionnaire

This form and declaration must be filled in and submitted before attending any class at the Institute.

The information you provide is treated with complete confidentiality. We ask as it will enable IYISL studio to get to know our clients better and ensure we remain a welcoming and inclusive space.

We don’t keep your medical information. We ask for medical information so that we can make sure it is safe for you to do yoga classes. Please note that classes are generally not suitable for pregnant women or anyone who has surgery within the last 6 months.

Please complete the form below

Name

First Name

Last Name

Email

Phone

Yoga experience

Other exercise

Age range

We want to ensure our spaces are welcoming and inclusive to all.

Gender

We want to ensure our spaces are welcoming and inclusive to all.

How did you hear about IYISL?

Web search

Social media

Poster or flyer

Word of mouth

IYISL e-newsletter opt-in

I am happy for you to send me the IYISL e-newsletter (approximately once a month) to keep me updated on new classes and workshops

I do not wish to receive the IYISL e-newsletter

MEDICAL QUESTIONNAIRE

IBS/ DIGESTIVE PROBLEMS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

SURGERY

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

ASTHMA, BREATHING, PULMONARY

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

BACK, NECK PAIN, SPINAL PROBLEMS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

BLOOD DISORDERS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

BROKEN, FRACTURED BONES

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

CANCER

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

CHEST PAIN

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

PREGNANCY/CHILDBIRTH/ LACTATION IN LAST 12 MONTHS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

DIABETES

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

DIZZINESS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

EAR TROUBLE

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

EPILEPSY

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

EYE PROBLEMS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

GYNAECOLOGICAL PROBLEMS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

HEART DISEASE

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

STROKE

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

HIGH BLOOD PRESSURE

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

HIV +

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

JOINT PAIN/ INJURY

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

ME

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

MS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

NOSE BLEEDS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

VARICOSE VEINS/ THROMBOSIS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

ARTHRITIC CONDITIONS

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

OTHER CONDITION FOR WHICH YOU HAD EXTENDED MEDICAL TREATMENT OR SUPERVISION

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

OTHER

Please specify the date and details of diagnosis and any treatment you are having. Type N/A if not applicable.

Please 'submit' your form to consent to the following:

I have filled in my medical information on the medical form above. I declare that I am not aware of any reason/s why I should not participate in moderately strenuous physical activity including work on specific muscles and joints. I undertake to remind the teacher of any injury and/or inform the teacher of any adverse change in my health before each class. I consent to being corrected and adjusted “hands-on” by the teacher.