Yoga Studio Participant Health Check-in
Please complete this health screening before participating in class. Your responses help us ensure a safe and supportive environment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Phone
*
Have you experienced any of the following symptoms in the past 7 days? (Select all that apply)
*
Fever or chills
Cough or sore throat
Shortness of breath
Muscle or body aches
Loss of taste or smell
None of the above
Other
Do you have any current injuries or medical conditions we should be aware of?
*
No
Yes (please specify below)
If yes, please describe your injuries or medical conditions.
Are you currently taking any medications that may affect your participation?
*
No
Yes (please specify below)
If yes, please list the medications.
Are you currently pregnant?
No
Yes (please specify below)
Prefer not to say
Have you had any surgeries in the last 12 months?
*
No
Yes (please specify below)
If yes, please provide details about your surgery.
Signature (Please sign below to confirm that the information provided is accurate and that you agree to the waiver above)
*
Submit Health Check-in
Submit Health Check-in
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