Health Questionnaire

Name*

First NameLast Name

Gender*

MaleFemale

Date of Birth*

DayMonthYear

Age

years

Which Class are you booking in for?*

Yoga/TRE/Stress Away/Workshop/Reiki

How did you hear about us?*

website/word of mouth/facebook/other (please state)

Address*

suburb, state, postcode

Email

example@example.com

Occupation

Whats the activity level at your job?

none (seated only)Moderate (light activity such as walking)High (heavy labor, very active)

Are you currently excersising regulary (at least 3x per week)?

YesNo

List any current diagnosed health challenges/injuries

If you are on any medications or drugs please state their benefit to you.

(tranquilliser/ pain relief etc)

What other therapists are you seeing currently?

Do you currently have any stresses or motivational challenges?

YesNoOther

Are you a current cigarette smoker?

YesNo

Which of the following best fit in with your goals? (Choose any that apply)*

Have you practised yoga or TRE with a qualified instructor before?*

YesNo

I give/do not give permission for photos/videos taken during this class to be used for promotional purposes on the Healing from the Heart website and Facebook pages.*

YesNo

1.) BOOKINGS

Bring your water bottl and a towel. Please wear comfy activewear.

2.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client, except in extenuating circumstances

3.) LATE ARRIVALS

Entry to an online class may be rejected if you are late. We do not wish to disturb other participants

4.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

5.) YOUR RESPONSIBILITY

You, as the student, take full responsibility for any injury, physical or emotional, during or after your online or in-person class.

It is your responsibility to provide a safe and responsible place in which to practice. Please take all due care to ensure you do not overstretch your body or attempt a pose which you may be unable to safely get out of. Please check in with your body and your state of mind prior to every class so that you are aware of when your body feels tired or energised or somewhere in between. sTREss Away is the practice of awareness of body and mind so remember to be aware.

The instructors endeavour to supply clear and informative instruction, with a visual experience, based on the training they have personally and professionally undertaken to bring them to the Teacher level. Every care is taken to ensure that all poses cater to varying levels so that you can take an easier option and progress further as your flexibility and fitness increase.

In rare cases, during TRE, a student may experience feelings of tiredness or may have emotions surface. The instructors will assist you wherever possible but it remains your responsibility to advise them if you are unsure about participating and to be very clear with your registration if you believe there is a likelihood of this happening. If you feel unwell during class and do not wish to continue please indicate to us. Then follow the steps given below and we will call you to check in at the conclusion of the class.

Self-regulation is required to enjoy a successful and safe practice. If you over-stretch or shake for too long, you will get overtired. Listen to your body and stay very present with what is happening in your body. 10-15 mins of actual shaking in which rests are taken is usually enough.

I understand that all personal information shared by students during this workshop is confidential and will not be shared by me outside of this workshop.

I understand that healing and/or information exchanged during this workshop is not designed to replace any existing medical therapy.

I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo

Registration and Health Form

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Please Read and accept The Following Ts &C's.