Yoga Registration Form Personal Details Your Name Your Email Your Date of Birth Your Phone Your Address Your Health Information 1. Please describe the current state of your health: PoorAverageGoodGreat 2. Are you taking any long-term prescription or over-the-counter medication? YesNo 3. Do you suffer from any of the following? AllergiesAIDS/HIVAsthmaBack PainChronic FatigueEpilepsyFibromyalgiaGlaucomaHearing LossHeart TroubleHerniaHypertensionOrthopedic ProblemsPregnancy (due date)Respiratory ProblemsSurgery (recent) 4. Please describe any other health or medical conditions below: 5. Please ask any questions or voice any concerns that you have about participating in yoga classes: 6. Is there anything else we should know about you or your health? I accept the terms of the Professional Yoga Disclosure and Release Form. Once you register above, please purchase your ticket.