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Yoga Lightness

Medical Details Form


Phone:                                             Email:

Number of medications taken daily______________

Number of mental health medications taken daily_________

My medications affect my balance _____, make me dizzy____, make me nauseous_________, Other_____________.

I have hearing loss: None  Some  Moderate   Severe

I have cataracts or macular degeneration that affect my vision:   Yes   No

I have been diagnosed with (please circle any that apply:

Macular Degeneration Wet Dry

Osteoporosis Stress fractures Wrist, hips, back, and/or _________


Heart condition - Heart Surgery or high blood pressure

Disc deterioration or inflammation, disc surgery

Arthritis: wrist hip knee   back and/or _______________

Hip replacement: right, left. Incision: front, back


Mental Health Issues_____________________







Medical information is collected to assist the teacher in providing any necessary modifications of poses and/or breathing so students participate in the class safely. The information is not seen by anyone other than the teacher and is kept in a locked cabinet.

Copyright 2016