In Balance Yoga Intake Form
Personal Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Age
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
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 apply to you:
Asthma
Diabetes
Epilepsy/Seizures
Pregnancy
Anxiety
Depression
Recent Surgery
Muscular/Soft Tissue Injury
Other medical condition/disability
For any of the checked conditions above, please describe:
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm