Intake Form

Name *

First

Last

Address *

Phone *

Email *

Emergency Contact and phone

Age Range *

Date submitted: *

Describe your previous yoga experience, if any:

Describe your lifestyle: active/sedentary, activites (physical, hobbies, etc), treatment preferences (massage, acupuncture, etc), nutrition/diet, daily routine/practices (wake/sleep, meditation, creative outlets, etc)

Describe any challenges that cause you pain/discomfort, or affect your overall health and wellbeing or range of motion/functionality:

Health Conditions: please indicate any areas that contribute to your health picture

Health Conditions: Please add any details regarding the conditions you've specified above. Please include treatment plans.

Is your doctor/health care provider aware that you are enrolling in a yoga practice?

yes
no

If you are pregnant:

in first trimester
in second trimester
in third trimester
my doctor/health care provider knows I’m taking yoga?

What are you hoping to gain through your practice of yoga?

Students are responsible for their own personal safety while engaged in yoga. Students agree to follow the instructions and cautions of the teacher to the best of their abilities. It is the student's responsibility to stop doing and activity that is painful, or creates a dizzy sensation, or is known to be unsuitable for their body. The student will inform the teacher of any current or new problem areas and is responsible for keeping the teacher informed of any changes in physical or emotional health status. It is important that the student asks for help or clarification when needed to allow the teacher to tailor the class content to suit individual requirements. Please check off the box below if you understand and agree to these statements.

I Agree

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