Online Intake Form

The answers to the following questions will help me to tailor my instructions to the class in our online format. Please know that you are welcome to come off mute during the class the ask questions and receive clarification. Please answer the following questions as fully as possible. Thanks.

Name *

First

Last

Email *

Practice Questions: Please let me know which of the following apply to you.

I can easily get down on the floor and back up again
I do the majority of my practice in a chair
Balancing is difficult for me
I have limited range of motion in some of my joints

Tell me about your body: any pain/discomfort? where? injuries? surgeries?

Overall Health and Well-being: How would you describe your general state of health and well-being? Are you coping with a health condition(s)? What is it and how does it effect you? Please include as much information as you are comfortable with, perhaps there are some yoga tools I can include in class that might help and perhaps there are some things to avoid.

Yoga goals: What do you want out of your practice?

The student is responsible for his/her own personal safety while engaged in yoga class. The student agrees to follow the instructions and cautions of the teacher to the best of his/her abilities. It is the student’s responsibility to stop doing any activity which is painful, or creates a dizzy sensation, or is known to be unsuitable for his/her body. The student has informed the instructor of any current problem areas and is responsible for keeping the instructor informed of any changes in physical or emotional health status. It is important that the student ask for help or clarification when needed to allow the instructor to tailor the class content to suit individual requirements. Please check off the box if you understand and agree to these statements. *

I Agree

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Online Intake Form

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