Oakridge Counselling & Wellness Centre Yoga Class
Health History & Waiver
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First Name Last Name Phone
Address City
Province Post Code Birthdate
Email    
How did you hear about Oak Yoga?
Have you practiced yoga before?
YesNo
If yes, please describe your practice:  
What are you hoping to experience
during or as a result of taking yoga classes?
Please indicate conditions you are experiencing or have experienced:
Cardiovascular Infections Head/Neck
high blood pressure hepatitis history of headaches
low blood pressure skin conditions history of migrains
chronic congestive heart failure TB vision problems
heart attack HIV vision loss
phlebitis/varicose veins herpes ear problems
stroke/CVA   hearing loss
pacemaker or similar device Other Conditions  
heart disease loss of sensation, where? Women
is there a family history of any of the above?YesNo pregnant, due:
  diabetes, onset: gynaecological conditions, what?
Respiratory
chronic cough allergies/hypersensitivity to what? Overall, how is your general health?
shortness of breath
bronchitis type of reaction:  
asthma epilepsy Primary Care Physician:
emphysema cancer, where?
  skin conditions, what? Physician Address:
is there a family history of any of the above?YesNo arthritis
  is there a family history of arthritis?
YesNo
Current Medications:
 Do you have any other medical conditions? (e.g. digestive conditions, haemophilia, osteoporosis, mental illness)?
YesNo
condition it treats: What?
Do you have any internal pins, wires, artificial joints or special equipment?YesNo
Are you currently receiving treatment from another health care professional? YesNo What?
If yes, for what? Where?
Surgery - date: Notes:
nature:
Injury - date:
nature:

Oakridge Counselling and Wellness Centre
Health Information and Waiver

 Waiver

I understand that, as with any activity that involves exercise, there are some risks associated with the practice of yoga. These risks are the result of increased cardiovascular activity in the body, and of the stretching and strengthening activities involved in yoga. I understand and accept these risks, and any questions I had have been answered to my satisfaction.

By signing this waiver I assume all risk of injury, loss or expense of any kind that may result during or after my participation in yoga classes at Oakridge Counselling and Wellness Centre. I will not hold Oakridge Counselling and Wellness Centre or its teachers liable for any injury or condition that arises through my participation in any class or workshop.

I certify that the above health information is correct, to the best of my knowledge, and I agree to inform both Oakridge Counselling and Wellness Centre and my yoga teacher of any health related changes I may experience in future.

Name:________________________________ Signature:_____________________________ Date: _____________

Thank you for taking the time to complete your Health History Form.

Credit Cards Accepted

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