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Health Questionnaire

Has your doctor ever restricted you from strenuous activity?
Have you ever been diagnosed with high blood pressure?
Have you ever been diagnosed with low blood pressure?
Are you affected with dizzy spells or light-headedness?
Do you suffer from frequent headaches?
Do you suffer from frequent migraine headaches?
Do you suffer from any regular chest pain?
Have you ever had a heart attack?
Do you suffer from heart disease?
Have you ever had a stroke?
Do you have Arteriosclerosis?
Do you have Diabetes?
Do you have Emphysema?
Do you have Asthma?
Do you have Chronic Bronchitis?
Do you have Chronic Fatigue?
Do you have Gout?
Have you ever been diagnosed with Rheumatoid Arthritis?
Have you ever been diagnosed with Osteoarthritis?
Have you ever been diagnosed with Degenerative Discs?
Have you ever been diagnosed with Spine Disease?
Have you ever been diagnosed with Spinal Fusion?
Have you ever been diagnosed with Joint Bursitis?
Have you ever been diagnosed with Cartilage or Ligament problems of the knee?
Have you ever been diagnosed with Hyperglycemia?
Have you ever been diagnosed with Hypoglycemia?
Have you ever been diagnosed with an Underactive Thyroid?
Have you ever been diagnosed with an Overactive Thyroid?
Are you Pregnant?
Do you smoke?
Have you been diagnosed with COVID-19?
Have you received vaccinaton for COVID-19?
Have you practiced yoga before?
Are you currently recovering from any injury or surgery?
Have you ever been involved in a sports or automobile accident?
Do you agree to being physically corrected and adjusted in poses?
Do you mind your photo being used in promotional material for Yogabodii? Names and privacy will always be respected.

TERMS AND CONDITIONS

The undersigned acknowledges that MISSED sessions will be counted in the total hours he/she has signed up for and the student is responsible for those sessions. Any missed classes can be made up only within a reasonable time period determined between the instructor and student and are not transferable to another person. There are no make-up classes available in session packages. The undersigned acknowledges that the paid fee is non-refundable, however the student has the right to change his/her class schedule within the course session. CANCELATION of Private sessions requires 24-hours’ notice to ensure no charge.

The undersigned expressly acknowledges that he/she will be engaging in Yoga movements while attending sessions with Sam Bederman at the Yogabodii studio, which could cause pain to the student. The student hereby states that he/she will be voluntarily participating in these activities and the student assumes all risks of injury, which might result from these activities.

The student hereby acknowledges that he/she has carefully read this waiver and releases and fully understands that is it a release of liability of Sam Bederman and agrees that such a waiver and release is reasonable and proper based on the nature of Sam Bederman’s business. The undersigned hereby waives and releases Sam Bederman from any claims that he/she may have against her or Yogabodii with respect to any loss or theft of personal property in respect of facilities operated by Sam Bederman (Yogabodii). Sam Bederman reserves the right to amend and or add to these rules and to adopt new rules, as it may deem necessary from time to time. (Mar 21)

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