Questionnaire

Yoga Rotorua Questionnaire

Before you come to your first Yoga Rotorua Class, please complete questionnaire below.
Any information given in the questionnaire will be confidential, equally you don't have to tell us about any conditions, but it would be helpful to ensure you get the most benefit from our sessions together.
Please don't navigate away from the online form while filling in or the form will clear.

* Indicates required field

Name *

First

Last

Email *

Have you practiced yoga before? *

Yes No

If so, what type and for how long? *

Phone Number *

What is your age? *

Do you suffer from any pain or discomfort in any of the following body areas? *

Knee Hip Lower Back Upper Back Shoulder Neck Other (e.g. recent injury or operation)

Please give a few details, if relevant *

Are you taking any medication? *

Yes No

If yes, please give details *

Females - Are you Pregnant? *

Yes No Maybe

What would you like to get out of these sessions? *

Do you suffer from any of the following? *

Sciatica Rheumatoid Arthritis Osteoarthritis Vertigo High Blood Pressure Low Blood Pressure Heart Problems Migraine Stress Anxiety Depression Period Pain Epilepsy Hernia Asthma Diabetes Eye Problems Other

Please give a few details, if relevant *

How did you hear about Yoga Rotorua? *

Friend Facebook Web Search Other

Which teacher's classes will you be attending at Yoga Rotorua? *

Jenny Ann Sarah Nadine Introduction to Yoga

Yoga Rotorua Terms and Conditions *

I agree to the Yoga Rotorua Terms and Conditions

Yoga Rotorua Terms and Conditions

Submit