Yoga for Cancer Care Health Questionnaire

Health Questionnaire and Waiver: Yoga For Cancer Care

Please complete and submit this form before attending your first Yoga For Cancer Care class with Cary. Brief answers are fine.
  • Include type of cancer, stage and lymph node involvement
  • In the boxes below, please enter the names of any health care providers who are currently treating you.
  •  
  • Aside from what you have already listed, has your doctor ever said that you should modify your physical activities, or restrict/limit your movements in any way? If so, please describe.
  • I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly.

    Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I affirm that my platelet count is at least 20,000 and all surgical incisions on my body have healed. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Cary Paul, any other Yoga for Cancer Care teacher, or the facility where class is held.

    Please enter your electronic signature (type name) below.

Leave a Reply