Health Questionnaire and Liability Waiver

The information that you provide on the this health questionnaire will help me understand your past and present state of health and allow me to modify our sessions together to better suit your needs.  All information provided will be held in the strictest confidence and will be used by Yoga Belly, LLC only to help me participate in yoga, and all other related classes, in the safest and most appropriate manner.

Name Occupation
Address City
State Zip
Date of Birth / /
What are your expectations from your yoga classes?
Do you suffer from any of the following medical conditions?
  • Arthritis
  • Asthma
  • Back Trouble
  • Chest Pain
  • Diabetes
  • Ear Trouble
  • Epilepsy
  • Eye Trouble
  • Heart Conditions
  • Hiatus Hernia
  • Hi / Lo Blood Pressure
  • Migraines
  • None - I'm super healthy!
If you have any other injury, illness, or disability not listed above, please describe it here.
Anything else you'd like me to know or other comments.
I recognize that exercise might be challenging and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain accelerated physical and emotional changes during yoga therapy, yoga, and exercise does exist. I acknowledge that it is my responsibility to notify Yoga Belly, LLC of any new health concerns as they arise and if I am experiencing pain or any other physical problem before, during or after any physical activity under the guidance of Yoga Belly, LLC.  I understand that as a result of my voluntary participation in herein programs I could suffer an injury. I recognize that an examination by a physician should be obtained prior to involvement in any exercise program. If I have chosen not to obtain a physician’s permission prior to beginning this exercise program with Yoga Belly, LLC, I hereby agree that I am doing so at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.