Classes, Privates + Healthcare Questionnaire Please fill out this form in preparation for our time together. Name * First Name Last Name Preferred Pronouns Email * Pre-activity Readiness Questionnaire This questionnaire is to ensure that you are healthy and able to take part in physical exercise, any potential issues that are flagged, will require you to seek your doctor’s consent before continuing. If you are between the ages of 15 and 69/pregnant, this form will tell you if you should check with your doctor before you significantly change your physical activity. If you are over 69 years of age and are not used to being very active, check with your doctor prior to committing. Checkbox Please read all questions carefully: and answer as appropriate. Has your doctor advised you NOT to partake in any physical exercise/you should only do physical exercise recommended by a doctor? (for example, a heart condition)? Carpal tunnel syndrome (wrist, finger, hand, forearm pain / numbness or tingling)? High/low blood pressure? Do you feel chest pain when you do physical activity? Have you recently had chest pain when you were not doing physical activity? Do you suffer from asthma, or breathing difficulties? Do you lose your balance because of dizziness or lose consciousness? Have you ever suffered from diabetes or epilepsy? Have you had any major surgeries? Are you/Is there a chance you could be pregnant? OR have you given birth in the past 6 weeks? If you have ticked any of the above: If you have ticked any of above Qs and need to give further information, please write in the box below. Please give any details of any injuries (old or new) that may impact your Yoga practice. Please tick the box below to confirm that the information you have given in this form is accurate, and that you understand it is your responsibility to check with your doctor if you have any difficulties or concerns about your ability to participate in a yoga class, and that you are responsible for notifying me if any of this information changes. * I confirm the information given is correct. Pre-booked classes must be paid for in advance. Invoices for private classes must be paid within 7 days. If you cancel within 12 hours before your Private, you will be subject to a 50% cancellation fee. Classes must be cancelled via email or phone and I will confirm receipt. Please tick the box to confirm you have read and understood this cancellation policy. * I understand the cancellation policy. By submitting this form you confirm you have read and accepted our terms and conditions, including the cancellation policy, and that you accept that Chloe Knowlden is not liable for any injury, or damages, to person or property, resulting from the taking part in this Yoga class. * I agree to these terms. thanking you!