YOGA FOR THOSE LIVING WITH CANCER QUESTIONNAIRE Health Questionnaire and Waiver: Yoga for Those living with Cancer and Yoga For Healing Please complete and submit this form before attending your first Yoga for Survivors or Yoga for Healing class. Brief answers are fine. Date Name*FirstLastPhone*EmailEnter EmailConfirm EmailDate of BirthMMDDYYYYEmergency Contact*FirstLastEmergency Contact Phone*Diagnosis*Include name/description of disease, condition or injuryDate of Diagnosis*MMDDYYYYPlease list any health care providers who are currently treating youAre you a cancer survivor?*YesNoDate of last chemotherapy treatmentMMDDYYYYHow many chemotherapy treatments remain?Date of last radiation treatmentMMDDYYYYNumber of radiation treatments remainingDescribe any side effects, sypmtoms, or limitations you are currently experiencing.*List all relevant/major surgeries you have had with approximate dates*List any other health problems you are currently experiencingIf you are interested in restoring strength and flexibility to a particular area of your body, please describe hereAre you able to do the following with relative ease and comfort (please select all that apply)*StandLie on your backLie on your stomachLie on your left sideLie on your right sideSitBreathe through your noseRestrictionsAside 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.Have you practiced yoga before? If so, please describe.What are your goals for participating in this class?Do you have any special concerns about participating in this class?How did you find out about this class?*Liability release*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 Ashrai Riggio and Ashrai Yoga & Wellness, or any facility where class is held. Please enter your electronic signature (type name) below.