Wellness with Lorie, LLC
Functional Yoga Coaching Intake Form
Date of Birth
Name and Relationship
Emergency Contact Phone
Occupation (current or previous, if retired)
Years at this Occupation
With whom (persons or animals) do you share your home?
Type of dwelling you live in (Single family home, apartment, etc)
Main Reason for Visit
Personal Health Goals
Describe any previous experience with yoga (include any postures you enjoy, would like to explore, or feel challenged in)
Recreational Activities you enjoy or would like to get back to
Have you experienced any of the following?
Arthritis or Joint Pain
Low Back Pain
Hips, Legs, Foot Pain
Numbness in Feet
Shoulder Pain or Stiffness
Numbness in Hands or Fingers
Numbness in Arms
Shortness of Breath
Please describe any other health conditions you’ve experienced and include dates. This may include: Surgeries, Hospitalizations, Accidents or Falls, Broken Bones, Joint Replacements, Heart Conditions, Head Injuries,etc.
Therapeutic Techniques You have used in the Past
CBD cream or Topical Analgesics
Pranayama (Yogic Breath Techniques)
Physical or Occupational Therapy
Disclaimer (Please Read Carefully) If at any time during the session, you feel discomfort or strain, gently come out of the posture, and let Lorie know what you are experiencing. You may rest at any time during the class. It is Important in Yoga that you listen to your body and respect its limits on any given day. I, the undersigned, understand that Yoga is not a substitute for Medical Attention, Examination, Diagnosis or Treatment. I should consult ‘My Doctor’ Prior to beginning any program, including Yoga for my overall wellbeing. I attest that the answers given to the above questions are accurate and current to the best of my ability. I recognize that it is my responsibility to notify Lorie of any serious illness or injury, or alterations in health, before the Yoga Session. I will not perform any postures to the extent of strain or pain.
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