Student Medical Form | natalieperry.com

First name

Last name

Phone

Email

Emergency contact name

Emergency contact number

Do you suffer from or have you been diagnosed with any of the following

Cardiac/heart problems

High blood pressure

Low blood pressure

Diabetes

Asthma or breathing problems

Epilepsy

Arthritis or Osteoporosis

Cancer

Digestive complaints

Chronic illness such as ME, Parkinson's or MS

Joint replacements

Recent injury (3 months or less)

Major surgery

Major accident

Minor surgery within last 2 years

Bone or stress fracture, including metal pins, plates or screws

Lower body problems (leg, hip, knee, ankle, foot

Upper body problems (arm, shoulder, elbow, wrist)

Muscle, ligament or tendon injuries

Neck problems (e.g. whiplash)

Back problems

Hyper mobile (excessive joint flexibility)

None of these

Please give details about any of the above, including relevant dates, medication you are currently taking and anything else you feel your instructor should know

Are you, or could you be pregnant? Please give any relevant details.

If you have indicated any medical conditions above, have you been cleared by a doctor or health professional to exercise?

Yes

No

How is your current fitness level (general movement, walking, running, cycling, swimming, etc)?

Please describe any previous/existing experience of yoga or barre:

What you would most like your yoga or barre sessions to help you with:

Yoga, barre and mindfulness meditation can be beneficial for everyone. However, it is up to the individual to take responsibility for their own physical and mental practice. It is better to build up slowly than to force and strain oneself – this applies to both physical and mental ‘exercise’. While Natalie Perry is a qualified yoga, mindfulness and barre instructor with extensive experience of teaching, she is not a medical or mental health professional. The services offered by Natalie Perry do not diagnose, cure, prevent or treat disease. They are designed to support, not replace medical, psychological or psychiatric treatment or therapy and Natalie Perry assumes no responsibility for injuries suffered while practicing the techniques and suggestions offered online, or in face-to-face sessions. Before beginning any new exercise program, please consult a licensed health care professional. This is especially important if: you have any health concerns (physical or mental); you have a pre-existing health condition/injury; you have recently had surgery or medical treatment; you are under the age of 16; you are pregnant.

Signature - please confirm your agreement to the above statement

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