Medical Details Form
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.