Munique Yoga Therapy Health Questionnaire

Please fill out one of these forms prior to attending a course or workshops both in-person or online with Muna Roberts.

Munique Yoga Therapy Health Questionnaire

Are you attending a yoga therapy session, course or workshop?(Required)

Please write the details (if a course or workshop please add title and date below).Thank you.

Name(Required)

Occupation

Email(Required)

Phone number(Required)

Address(Required)

Date of birth

Gender (optional)

Emergency contact details

GP Name

GP Phone number

Emergency Contact Name & Relationship

Emergency Contact phone number

Your health

1. Are you currently taking any medication (prescribed by your doctor or bought over the counter, and including herbal and other supplements)? If so please give details.

2. Have you had any major illnesses or accidents? If so please give details.

3. Do you currently have any health problems? If so please give details, including onset, diagnosis, severity, and treatment.

4. Have you sought or are you currently under the care of a therapist/psychotherapist/social worker?

5. Have you ever been to any alternative or complementary practitioners? If so, please give details.

6. Are there any specific physical or psychological sensitivities which we should be aware of to better support you?

7. Do you feel there are any areas of your body in which you have restricted movement, or otherwise aches/pains/lack of flexibility?

8. Please tick any of the following that you currently suffer from or have suffered from in the past:

9. Please list any other physical or mental health problem you suffer from or have suffered from that are not listed above, or use this space to provide any further details you would like to share

10. How would you describe the quality of your sleep? Are there any specific factors that affect the quality of your sleep?

11. What time do you usually go to bed and how many hours sleep do you usually get?

Your lifestyle

1. Do you smoke? If yes, how many per day?

2. Do you drink alcohol? If yes, how many units per week?

3. How many meals do you eat per day?

4. How would you describe your diet? E.g. vegetarian, vegan, some meat, high sugar

5. Do you drink coffee? If yes, how many cups per day?

6. Do you exercise? If yes, what kind and how often?

7. When do you feel most energetic? Morning/afternoon/evening?

8. Do you travel for work and if so, by what method?

9. If you work, is your job: Sedentary/ Office-based/ Active / Manual / Other

10. What are your daily working hours?

Yoga Practice

1. Have you practised yoga before? If yes, what style and for how long?

2. What was your experience of yoga?

3. Do you have a view as to how often would you like to practise?

Please select

Once a week

Three times a week

Weekdays only

Weekends only

Daily

Not sure

4. How much time do you have available in one block for practice?

Please select

Once a week

Two hours

One hour

30 minutes

10 minutes

6. Which of the following aspects of yoga interest you (you may circle more than one):

Please select

Building strength

Building fitness

Improving flexibility

Working towards mental and emotional balance

Chanting / musical therapy

Spiritual dimension

6. Do you feel that you would be suited to a yoga practice that is:

Please select

Slow and strong

Light and flowing

Energetic and active

Not sure

7. Select any of the following that you feel reflect your personality:

Please select

Practical

Creative

Spiritual

No-nonsense

Open-minded

Open-hearted

Munique Yoga Therapy honours your privacy, and complies with GDPR regulations – for more information, please refer to policy information on our website (https://muniqueyogatherapy.com/privacy-policy/). All information is confidential, and every effort will be made to ensure that your identity is protected. All discussions between yoga therapist and client are strictly confidential. There are, however, some limitations to confidentiality that you need to be aware of: as your yoga therapist, I reserve the right to break confidentiality and contact the appropriate services should I consider you to be at risk of harm to yourself or to/from others. I will make every effort to discuss this with you before taking any action. Any personal information given to us on this form is held securely by your therapist only. It will only be used for the purpose of providing safe yoga therapy and will never be passed to a third-party. The information you have given on this form will be destroyed within 7 years.

Consent(Required)

I agree

By signing this form, I consent to my information being used in this way for the length of time stated above.

By signing this form, I confirm that all to the best of my knowledge all the information provided in this form is accurate and up to date. I understand that yoga is a practice which involves physical movement, breathing, and meditation, which induces specific physiological and psychological changes. I represent that to the best of my knowledge and belief I am able to participate in these aforementioned activities. In the event that I am unsure or if I have questions regarding these practices I will speak to my doctor and my yoga therapy practitioner to receive further counsel and will follow his/her advice. I understand that yoga therapy does involve movement and that like with any physical practice, in the unlikely event that injury occurs, I will not hold my Yoga Therapist liable. I hereby assume full responsibility for any risk or injury, arising out of or related to my participation and or instruction in yoga therapy. Whilst it can be hugely beneficial, I know that yoga therapy is not a substitute for any care I may be receiving from a professional primary health care provider and that it is advisable to continue any therapy work, in conjunction with yoga therapy. I understand that if a yoga therapy session is conducted online, I am responsible for my own health and well-being during the entire session. I understand it is my responsibility to safely set up my own space with which to undertake the session. It is my responsibility to follow the directions given to me by the trainee yoga therapist, if for any reason I feel these directions feel they do not meet my needs, I must immediately alert the trainee yoga therapist, while jointly ceasing any practice that feels it is not of benefit to me. I fully understand that any practitioner or therapist recommended to me, or to whom I am referred, by any partner or employee of the Munique Yoga Therapy is not an employee, agent or affiliate of the Munique Yoga Therapy, and neither Munique Yoga Therapy nor its partners or employees are liable for any act or omission of any such practitioner or therapist. I understand that I am responsible for notifying my yoga therapist of any changes to my health or medical conditions that may affect the treatment carried out by the yoga therapist.

We have a 24-hour cancellation policy – appointments not cancelled or cancelled on the day of your session are charged in full. If the client arrives late he/she will be entitled to the remaining time of the treatment. Should the therapist arrive less than 15 minutes late for your treatment she will still carry out the treatment for the full amount of time that you have booked. Should the therapist arrive more than 15 minutes late or have to cancel a treatment with less than 24 hours notice you will be entitled to a complimentary session.