In Balance Yoga Intake Form
Personal Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Gender
Female
Male
Non-binary
Emergency contact name and number
Have you done yoga before?
Yes
No
If you answered "yes" to the above question, how long have you practice for?
Would you like to receive In Balance Health Yoga's monthly newsletter to hear about schedule updates and yoga education through the blog?
Yes
No
How did you hear about the services at In Balance Yoga?
Health History
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
Is your doctor currently prescribing medication (e.g. water pills) for your heart or blood pressure condition?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem (e.g. back, knee, hip) that could be made worse by a change in your physical activity?
Yes
No
If "yes" please describe:
Do you know of any other reason why you should not do physical exercise?
Yes
No
If "yes" please describe:
Please indicate any of the following conditions that are current and apply to you:
Asthma
Diabetes
Epilepsy/Seizures
Pregnancy
Anxiety
Depression
Trauma
Recent Surgery
Muscular/Soft Tissue Injury
Autoimmune Condition
Chronic Pain
Other Medical Condition/Disability
If there is any relevant information, from checked conditions above, that would affect your participation in yoga, please describe:
I understand that any activities I undertake at In Balance Health Yoga may require physical exertion that could cause injury, am fully aware of the risks involved and understand it is my responsibility to consult with a physician prior to participation. I hereby agree to assume full responsibility for any manner of loss, injury, claim or damage whatsoever, known or unknown, incurred as a result of same and I, my heirs, executors, administrators or assigns expressly release and forever discharge In Balance Health Yoga and the Program Instructors, and waive any claim against them for any loss, injury, claim or damage sustained as a result of my attendance and/or participation.
I agree
Submit
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