5 Koshas LLC
Health and Interests Information
This information is kept confidential.
Please enter a valid phone number.
Emergency Contact Name and Phone Number
Please list any pain or injuries that you have related to your back/spine, neck, jaws, shoulders, elbows, wrists, hips, knees and feet:
Please list any medical conditions or injuries or accidents that currently or occasionally contribute to pain in your body:
Do you have any health or wellness concerns or medical conditions that may impact your ability to exercise?
Are you on any medications that lower your blood pressure or make you dizzy or light-headed or impact your balance? If yes, please explain:
What do you do for work? Do you get any tension or pain in your body from work activities?
What are your hobbies? What do you do to stay active? Do any of these activities create any tension or pain in your body?
What benefit would you like to gain from classes?
For Yoga classes: Are you new to yoga? What would you say is your experience level with yoga?
Health care professional
Please check the boxes of your yoga class and wellness interests:
Feldenkrais Awareness Through Movement
Outdoor/Rib Mountain Yoga
Strength Training Yoga
Stress Relief Yoga
Yoga Philosophy & Sutras Study
Yoga Teacher Training
Should be Empty: