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Your Health Declaration

Please complete the following form to help us understand your physical condition.

First Name

Email Address (Mandatory)

Last Name

Medical conditions: Please read through the list, placing a tick in the box if you have any of the medical conditions as they may require specific modifications to your yoga practice.

abdominal disorder or recent surgery

arthritis (degeneration/osteo or rheumatoid)

back pain (if known cause, please state)

knee problems: hairline fracture/injuriy/surgery/ligament issues

hip problem: due to lower back issues/slip disc/hip surgery

shoulder/neck problems: injuries e.g cervical: C5/C6/etc. vertebrae: fracture/dislocation etc.

heart disorders: bypass before/murmur/palpitations etc.

high blood pressure: giddiness/nauseating/non-stop perspiration etc.

low blood pressure: giddiness/nauseating when inverted

asthma/bronchitis/chest pain

diabetes: state type(s), level, medication

auto immune disorder (e.g. M.E., M.S., Lupus etc)

epilepsy

anxiety/depression

sensory disorder affecting eyes/eyes socket (e.g. glaucoma) nd ears

balance affecting disorder/vertigo

recurring/old injuries that may still trouble you

pregnancy stage/given birth in the last six weeks

any recent minor/major surgery less than 6 months: Please state in "...any other comments"

other medical conditions not covered above that might be adversely affected by yoga practice

Choose an option (Vaccination Status)

Remarks Box:

If you do not have any of the above medical conditions By ticking this box you confirm that you have no current or underlying medical conditions, concerns or injuries and that you are fully aware of the advice given.

I declare that the info I’ve provided is accurate & complete and accept the terms and conditionsView terms of use

We appreciate your kind submission, thank you!

innerspacestudiosg@gmail.com

+65 9877 7750 (via WhatsApp Only)

3 Coleman Street #03-40 Peninsula Shopping Centre Singapore 179804

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