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Please fill in the fields so that we have a better picture of your current state of health.
Or you can download the PDF document and you can send it to me at:
Please list any medications that you are taking:
Please list any supplements that you are taking:
Please indicate if you have experienced any of the following health conditions:
Blood clotting disorders
Any accidental injury
Fainting spells or dizziness
Circulatory or heart problems
High blood pressure
Numbness or tingling
Back or neck discomfort
Low Blood Pressure
Please take time to thoroughly explain any of the above checked health conditions:
Do you perform any repetitive movement or sustained position in your work, sport or hobby? If so, what activities?
… and how often?
Do you sit for long hours at a workstation, computer or driving?
What level of stress are you experiencing most recently?
How is regular Appetite?
How is Bowl movements?
How is sleeping quality?
Daily water Intake?
< 1 Liter
1 bis 2 Liter
> 2 Liter
How does stress affect your life?
What is the primary reason or goal for your Yoga practice?
Have you practiced Yoga (Postures) and Pranayama (Breath Exercise)? And what Yogastyle?
Have you practiced Meditation before? And what types?
Are you familiar with any of these words?
Will you please share your opinion/perception on Yoga and Yoga-Practices if you have practiced before?
I the undersigned hereby declare that I have read and understood the medical and health questionnaire, and that all the answers to all the questions by myself: I declare that I have given full and correct information about my past and present medical condition.
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