Home
Classes
Membership
Store
- Apparel
- Equipment
  - Blocks
  - Bolsters
  - Straps
Contact Us
Waiver
My account

Consent & Liability Waiver

You are here: Home / Consent & Liability Waiver

Physical Activity Readiness Questionnaire – PAR-Q

If you are between the ages of 18 and 69, the PAR-Q will highlight whether you should consult your GP prior to significantly changing your physical and energetic activity patterns. If you are over 69 years of age and are not used to being very active, or using energy to heal, please check with your doctor prior. Common sense is your best guide when answering these following questions.

Questions 1-7 relate specifically to physical practice. Please read carefully and answer each one honestly circling ‘YES’ or ‘NO’.

Q1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

NOYES

Q2. Do you feel pain in your chest when you undertake physical activity?

NOYES

Q3. In the past month, have you had a chest pain when you were not undertaking Physical activity?

NOYES

Q4. Do you lose your balance due to dizziness or do you ever lose consciousness?

NOYES

Q5. Do you have a bone or joint problem (for example: back, knee or hip) that could be made worse by a change in your physical activity?

NOYES

Q6. Has your Doctor ever recommended medication for blood pressure or a heart condition? Is your Doctor currently prescribing medication for your blood pressure or a heart condition?

NOYES

Q6a. Do you suffer from high or low blood pressure?

NOYES

Q7. Do you know of any other reason why you should not undertake any physical Activity? If yes, briefly describe below.

NOYES

Q7 (a). Any other reason?

Questions 8-21 relate specifically to Sound healing therapy. Before deciding to attend a sound healing bath or blended therapy using sound healing instruments, please be aware that there are certain illnesses, conditions and circumstances that may prevent you from participating. If you answer yes to one or more of the following questions, you MUST consult your GP prior, or at the very least, discuss with Yoga Junkie or another practitioner.

Please read carefully and answer each question honestly selecting YES or NO.

Q8. Do you suffer with epilepsy? (Specifically, sound induced epilepsy)

NOYES

Q9. Do you have Parkinson's Disease and a deep brain stimulation device (DBS) to treat your condition?

NOYES

Q10. Do you have any other neurological disease not listed? If yes, please provide details.

NOYES

Q11. Do you have a pacemaker, coronary stent, cardiac shunt, artificial heart valves, implantable cardioverter defibrillator (ICD), metal inserts, metal implants, metal screws or metal staples? Please provide details.

NOYES

Q12. Do you suffer from polyneuropathy or hemiparesis?

NOYES

Q12a. Do you have carotid stenosis or carotid atherosclerosis?

NOYES

Q12b. Do you have artificial joints, inflamed joints and veins or diseased veins?

NOYES

Q12c. Do you have inflamed skin disorders or weeping eczema?

NOYES

Q12d. Do you have any implants?

NOYES

>Q12e Please provide details.

Q13. Do you suffer from SEVERE mental illness? A brief consultation prior to participating in class is strongly recommended.

NOYES

Q14. Is there a possibility that you are pregnant?

NOYES

Q14 (a). If yes, are you 12w or less? A brief consultation prior to participating in class is recommended

NOYES

Q15. Are you experiencing a fever, had severe inflammation or have any open wounds? Please provide details.

NOYES

Q16. Are you recovering from recent surgery? Please provide details.

NOYES

Q17. Have you suffered from whiplash in the last 3 days? Please provide details.

NOYES

Q18. Do you have a metal allergy?

NOYES

Q19. Are you presenting any symptoms of COVID19?

NOYES

Q20. Sound healing is the use of sacred instruments or voice to release energetic blockages inducing a state of ease and harmony in the body. It promotes relaxation and releases tension. Trauma survivors often experience feelings of tension and anxiety, making it harder for the mind and body to heal. When relaxation happens, we can take a step further on the healing journey.
Traditional approaches to healing from trauma include talk-based, cognitive psychotherapies, but these modalities often fail to achieve lasting, somatic change. The use of vibration in sound healing therapies directly affects the body, promoting relaxation and well-being, paving the way for recovery from our trauma symptoms.
Here at YJ, we categorise trauma as the 'big T' or 'little t'. Big T meaning trauma that affects you on a daily basis, and 'little t', that ignites your trauma in certain circumstances. Both are as significant to us here, as they are to you. So even though we do not ask you to share what troubles you, we really need to know what space to hold for you to support you.
Sound healing helps with the release of layers of emotion, and can be overwhelming, but in turn, such a welcomed release, but your well-being is of paramount importance to us, so please help us to help you.
Choose the capital T or lower-case T in the column opposite so we know your needs.
Of course, sound healing is not recommended to be used as a single approach to trauma recovery. It acts well as a complementary therapy in conjunction with other, evidence-based modalities, like psychotherapy, medication for symptom management if necessary.

tT

Q21. Are there any other concerns you may have that you wish to discuss?

NOYES

Q22. Do you have eye problems or glaucoma?

NOYES

Q23. Are you taking any medication? If so, please state medication you are taking and give further details if necessary.

NOYES

>Q23 Please provide details.

Q24. Are you allergic to anything? If so, please state what you are allergic to, and give further details if necessary.

NOYES

>Q24 Please provide details.

Yes, to one or more questions: You should consult with your GP to clarify that it is safe for you to become physically or energetically active at this present time and in your current state of health.

No to all questions: You can be reasonably sure that it is safe for you to participate in physical and energetic activity, gradually building up from your current level of ability. A full fitness appraisal can help to determine your fitness level.

Full Name

Email Address

“I have read, understood, accurately and honestly, completed this questionnaire and confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.”

By Submitting this form I agree to the details stipulated above

*Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the 7 questions. It is your responsibility to keep information updated.

Show Details

0 out of 5

1:1 Tailored Sessions

View Class

Home
Contact Us
Waiver
Terms & Conditions

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Cookie settings ACCEPT

Privacy & Cookies Policy

Privacy Overview

This website uses cookies to improve your experience while you navigate through the website. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may have an effect on your browsing experience.

Necessary

Always Enabled

Necessary cookies are absolutely essential for the website to function properly. This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information.

Non-necessary

Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. It is mandatory to procure user consent prior to running these cookies on your website.

SAVE & ACCEPT