Yoga Retreat Health Questionnaire

Vital Yoga retreat health, medication and allergy information

If you’ve been directed here, then your retreat with us is just around the corner. Please take your time to look through the following questions and answer them as clearly and as fully as you can. We need to know how to best nourish and support you throughout your Yoga retreat, so please tell us everything we need to know, and be confident that all of the information you share with us is handled in the strictest confidence. If there’s something that you’d prefer to mention one-to-one, then feel free to get in touch with us directly as well.

 

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We offer a vegetarian diet while on retreat. Do you have a severe food allergy, any sensitivities or a medically diagnosed intolerance of any kind? (required)

Do you suffer from pulled ligaments or tendons?(required)

Are you currently taking any medicines or receiving any medical treatment? (required)

How often do you practice Yoga?(required)

How long have you practiced?(required)

Have you attended a retreat before?(required)

Do you suffer with, or have you suffered from chest pains?(required)

Do you suffer, or have you suffered from heart murmurs?(required)

Do you suffer with, or have you suffered from fainting?(required)

Do you suffer with, or have you suffered from palpitations?(required)

Do you suffer with, or have you suffered from ankle edema?(required)

Have you suffered from a stroke?(required)

Do you suffer with, or have you suffered from hypertension?(required)

Do you suffer with, or have you suffered from seizures?(required)

Do you suffer with, or have you suffered from high cholesterol?(required)

Do you suffer with, or have you suffered from diabetes?

Do you suffer with, or have you suffered from lung disease?(required)

Do you suffer with, or have you suffered from ulcers?(required)

Do you suffer with, or have you suffered from cancer?(required)

Do you suffer with, or have you suffered from arthritis?(required)

Do you suffer with, or have you suffered from osteoporosis?(required)

Do you suffer with, or have you suffered from postural problems?(required)

Do you suffer with, or have you suffered from epilepsy?(required)

Do you suffer with, or have you suffered from a recent fracture?(required)

Do you suffer with, or have you suffered from a recent sprain or strain?(required)

Do you suffer, or have you suffered from a recent operation?(required)

Do you suffer, or have you suffered from high or low blood pressure?(required)

Do you suffer with, or have you suffered from respiratory problems?(required)

Do you suffer, or have you suffered from heart attacks?(required)

 

Waiver of Liability and Informed Consent Release for Yoga practice on retreat

I am participating in a programme of instruction in Yoga classes offered at this retreat. I have been advised and I understand that participation in Yoga, like any physical conditioning or exercise programme presents some unavoidable risk of injury, especially to people who have pre‐existing injuries, illness or medical disabilities.

I recognise that many changes may occur as a result of these Yoga lessons, including possible short‐term aggravation of some symptoms, feelings of tiredness, light‐headedness, increased energy, mood changes etc. 

I also understand that a medical evaluation is advisable before commencing anyprogramme of physical conditioning or exercise.

I have and will continue to keep my Yoga instructor on the retreat informed of any physical condition or disability, which would prevent or limit my participation in an exercise programme.

I acknowledge that, although the programme may have substantial physical benefits, my Yoga instructor on the retreat is not engaged in diagnosing or treating medical diseases or deficiencies.

I expressly assume all risks of my participation in this Yoga programme and waive any claim, which I might otherwise bring against my Yoga instructor on this retreat or against the operators of the retreat as a result of injuries from or relating to my participation in this programme.

I confirm that all the information provided in this questionnaire is true to the best of my knowledge and I am not aware of any reason why I should not participate in this retreat or these classes.

By signing below I agree to the above:

 

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Thank you so much for helping us gather all the information we need to look after you in the best way we can.

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