Initial student questionairre.


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Initial student questionairre.

  1. 1. College of Western Idaho Yoga Instructor: Barbara Harris 2012 Yoga is, among other things, a physical endeavor. The instructor will be able to make adjustments with props and alternative poses to accommodate normal day to day issues and minor physical restrictions. However, if you need major accommodations to complete this class you will be referred to the Student Services area for assistance. The following information will help the instructor to assist you with your practice and assure your safety. If you prefer to discuss issues directly with the instructor or with Student Services please let me know on the first day of class Student Name: Date Have you had previous instruction in Yoga? If yes when and how long did you study Are you currently involved in a regular exercise program? What kind of program How often do you participate in this activity (xs/per week) Do you have any of the following chronic medical condition? __Allergies Do you carry an Epi Pen______ __Chronic back problems Please explain the nature of the problem __Detached Retina Other____________________ __Glaucoma Explanation: Are you currently under the care of a physician for a specific issue? Explain: Do you take any medication on a regular basis? Have you had a serious injury that causes reoccurring pain or weakness? Are you currently dealing with an injury? ( Even if a minor injury if it will restrict your mobility) What kind of injury When did it occur? Have you had surgery in the last 18 months? What kind of surgery When did it occur?
  2. 2. Name Page #2 Are you pregnant? What is your expected delivery date? If you are pregnant you should wait until after your delivery to take Beginning Yoga. Your safety and the safety of your child is our up-most concern. If you become pregnant during the semester, you will need to consult your physician about continuing participation in a yoga class. You should explain to him/her that Iyengar Yoga is very physically demanding , it is not “sitting and breathing” and can have a profound effect on the entire body. Written consent from the physician will be needed so you can continue the class. Modifications will be made as your pregnancy progresses. Please inform the instructor as early as possible of your condition changes in hormone levels can make the body more vulnerable to injury. Is there ANY reason that you will not be able to participate in class and complete the required activities of this class?YES_____________NO___________________ Is there any other information you think would be helpful for the instructor to know to help you have a better experience in the yoga class? Female students should inform the instructor prior to the beginning of class on days of maximum menstrual flow. If you are in the beginning or the end of you cycle and flow is minimal your participation will not be restricted. There are poses that are contra-indicated for menstruating women in maximum flow. Accommodations will be made discreetly. If you have painful menstruation please let me know, I will provide accommodations for your pain. Any student who comes to class not feeling well, please inform the instructor, accommodations can sometimes be made to assist you. If you think you could be contagious……. Stay home I have been informed of the physical nature of yoga and I understand my responsibility to inform the instructor of any physical injuries or illnesses prior to participation in any class. I understand that I am ultimately responsible for my own safety. Signature:_____________________________________________________________________ Date________________