healthy back programme registration form – Dru Yoga Cape Town and Buteyko Instruction

Name

First Name

Surname

Phone

Email

Date of birth:

Occupation

Please provide the following details and permission to contact these people in case of emergency only. They will never be used for any other reason.

Name of health care practitioner

Title

Name

Number

Name of person to contact in case of emergency:

Name

Surname

Phone

What would you like to gain from coming to this Healthy Back Class?

What is your previous experience of yoga?

none

minimal

regular

experienced

If you have a problem with your back or neck, what is your understanding of it?

How long have you been experiencing these problems?

Have you ever been given a diagnosis of back or neck pain?

yes

no

If yes. Who gave you that diagnosis?

Please describe the diagnosis

Have you had any medical treatment for your back, including physiotherapy, osteopathy or chiropractic?

yes

no

Are you currently receiving treatment?

yes

no

Are there any specific movements that trigger your symptoms? Or ease them?

Do you have any of the following symptoms due to your back condition?

Numbness, weakness, pins and needles in both legs

Numbness in your inner thighs and around your genitals

Have you had any unexplained weight loss?

Unsteadiness on your feet

Loss of control or feeling around your bladder or bowels

Personal health history (tick any that apply)

Any other?

If you have ticked any of the above, please give details

Are you or have you recently been pregnant?

yes

no

Are you taking any medication? If yes, please give details.

In this class we will be doing exercises in a variety of different positions:

Are you able to get up and down from the floor independently?

yes

no

Are you able to lie on your back for 10 minutes?

yes

no

Are you able to lie on your front for 10 minutes?

yes

no

Are you able to be on all fours, hands and knees? (positions can, of course, be adapted for comfort)

yes

no

Please download the image by right clicking on it. Indicate on the body chart any areas of aching, pain, pins & needles or numbness.  If any of these are constant, please encircle that area

Please email or WhatsApp it to me.

body

By submitting this form I acknowledge that the above information is correct. All personal information will be only be used for the purposes of communication during this course.