Pre Meditation Questionnaire | Stacey Grey Yoga

Pre-Meditation Questionnaire

Please Note: You only need to complete this form if it’s your first time attending a meditation class with me.

First name

Last name

Birthday

Day

Month

Year

Phone

Are you currently Meditating?

Yes

Have you Meditated before?

Yes

Do you have low blood pressure?

Yes

Do you have unmedicated Epilepsy?

Yes

Are you currently taking any medication? If yes, please state:

Do you currently have any physical, medical, mental or emotional conditions that can be adversely affected by me teaching you how to Meditate or by taking part in Meditation sessions? If so, please give details.If you are not sure, please discuss with me.

By participating in these sessions, I understand and acknowledge that Meditation may involve emotional, physical or psycological responses. If I experience discomfort or distress during the session, I will stop and inform Stacey Grey or my healthcare professional. Stacey Grey disclaims all liability directly or indirectly for any injury, loss or damage incurred with initiating a new Meditation program or during sessions. I agree to take full responsibility for my wellbeing during and after each session. I understand and accept these risks.

Signature

Signature field is empty.

Date

Day

Month

Year

STACEY GREY

Yoga, Meditation & Pilates

Pre-Meditation Questionnaire