Karuna Yoga Vidya Peetham
www.karunayoga.in
+91 96865 49129
[email protected]
Health Assessment Form
Name: Ms/Mrs/Mr _____________________________________________ Date: ________________
Address: ______________________________________________________________________
Date of Birth: ________________ Height: ___________ Weight: __________
Email: ___________________________ Mobile/Landline #: ____________________________
Kindly answer the following sincerely. Please underline wherever necessary:-
What is your purpose in learning yoga? i) Fitness ii) Relaxation iii) De-stress iv) Therapy v) Spiritual vi) Other
Any prior experience of yoga? If yes, where :____________________________________________________________
What is your level of fitness? i) Excellent ii) Good iii) Average iv) Poor
What do you hope to achieve from being a practitioner of yoga?
_________________________________________________
Have you suffered from any of the following conditions:
i) High Blood Pressure ii) Low Blood Pressure iii) Heart Disease/Chest Pain iv) Diabetes v) Epilepsy vi) Arthritis
vii) Asthma/Bronchitis viii) Anxiety/Depression ix) Headache/Migraine x) Insomnia/Sleeplessness xi) Hernia xii)Eye Strain xiii)
Digestive Disorders like Constipation/IBS/Gastritis/Acidity/Indigestion/Peptic Ulcer/Ulcerative Colitis/Piles .
Do you suffer from: i) Over Weight ii) Under weight ii) Anger iii) Fatigue iv) Excessive Stiffness v) Neck Pain
vi) Back pain - Low back pain/Mid Back pain/Upper Back pain vii) Joint Pain – Knee Pain/Ankle Pain/ Toe pain/Hip Pain
/Shoulder pain/ Elbow pain/ Wrist pain/finger pain .
For Ladies only: Do you suffer from – i) Amenorrhoea ii) Dysmenorrhoea iii) Menorrhagia iv) Metrorrhagia
v) Hypomenorrhagia vi) Oligomenorrhoea vii) Polymenorrhoea viii) Premenstrual Tension
For Ladies only: Kindly mention if you are you pregnant ___________________________________________________
Have you ever had surgery? If yes, what kind of surgery and when? ___________________________________________
Are you on any medication? If yes, for what and what type of medicine? ________________________________________
Have you ever had an accident? If yes, when did it happen and how you were injured? ______________________________
_____________________________________________________________________________________________
Did you suffer with any major health problem in the past? If yes, kindly specify details with the date of occurrence.
_____________________________________________________________________________________________
Have you suffered from any illness in the last 3 months? If yes, kindly specify details:
_____________________________________________________________________________________________
Is there any further relevant information regarding your health that you think we should be aware of?
____________________________________________________________________________________________
Declaration:-
I realize that the Yoga Training I receive is not carried out by medical doctors, but by qualified yoga teachers/ yoga therapists, and I
assure you that all the above information is correct and complete at the time of signing. I hereby release the yoga teachers/yoga
therapists, their parent affiliates, officers, directors and agents from all the claims, actions, costs, losses, expenses, damages, that I
might have now or in the future for any injuries, death, mental impairment and damages resulting from my yoga training. Such release is
binding upon my heirs, successors and assignees. I am fully knowledgeable as to the training I am undergoing, as well as my physical
limitations and I agree to indemnify and keep yoga teachers/yoga therapists indemnified, against any or all claims whatsoever or loss or
damage.
_____________________________ ______________
Signature of the Participant Place
Karuna Yoga Vidya Peetham
No. 162/1(ground floor), 7th ABC Cross, Venkatapura Main Road Koramangala, Bangalore - 560 034
(India)
