Your Name:_____________________________ Date: ___/___/___

1. Do you have back or hip discomfort, displaced vertebrae, spurs, arthritis, or other physical limitations? Circle one YES NO
If you answered yes, please consult your physician before doing any yoga practice.

2. Are you pregnant? Circle one YES NO
Pregnant women should avoid deep forward bends or other poses that constrict or twist the abdomen.

3. Do you have high blood pressure, heart problems, detached retina, or ear problems? Circle one YES NO
Do not do the inverted poses if you have any of these health problems.

In the space below, please let me know if you have any other health problems not
listed above that may interfere with your yoga practice. Thank you.