Yoga for the Special Child ®
Yoga for the Special Child ®
4812 Benchmark Ct. , Sarasota , FL 34231
Telephone: (941) 925-9677 Fax: (941) 925-9433
E-Mail: Info@specialyoga.com Web: www.specialyoga.com
* Contact for Reno Programs at The Yoga Center : Telephone (775) 881-7848 *
E-mail: Kathy@theyogacenterreno.com
QUESTIONNAIRE FOR PARENTS VISITING WITH THEIR CHILD
** PROGRAM LOCATION: ____________________ PROGRAM DATE: _____________________
1. Child's Name: _______________________________________________________________
2. Mother's Name: _____________________________________________________________
3. Father's Name: ______________________________________________________________
4. Address: ___________________________________________________________________
5. Telephone Number________________________E-mail______________________________
6. Child's Date of Birth:__________________________________________________________
7. Comments on labor and delivery:________________________________________________
8. Have any family members practiced yoga? ______If so, how long?______________________
9. What was the diagnosis of your child at birth?_______________________________________
_____________________________________________________________________________
10. What are the physical symptoms of the disability? ___________________________________
_____________________________________________________________________________
11. Does your child have convulsions? ______________________________________________
12. Does your child have a cardiac problem? _________________________________________
13. Does your child have a problem with his or her spinal column?_______In what area?_______
_____________________________________________________________________________
14. Has your child undergone surgery?______________________________________________
15. What medication does your child receive?_________________________________________
16. Can you think of any other reason such as a recent physical illness or chronic condition that
might contraindicate the practice of certain yoga poses?_________________________________
17. Is your child's motor development delayed?________________________________________
_____________________________________________________________________________
18. Would you characterize your child as happy, aggressive, easygoing, enthusiastic, passive,
excitable, depressed, introverted or extroverted?_______________________________________
19. Will your child require handicap access and/or other handicap facilities? (Please describe)
_____________________________________________________________________________
PLEASE NOTE: You will be contacted prior to the Program Demonstration Session. We will provide you with as much time as
possible for you to arrange transportation etc. It is also important that you remain with your child throughout the demonstration.