Health and Interests Information-FOR PP CUSTOMERS & LINKED ON 5K WEBSITE

5 Koshas LLC

Health and Interests Information
This information is kept confidential.
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
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?
Background:

Health care professionalEducator
Please check the boxes of your yoga class and wellness interests:

Acupuncture/Oriental MedicineBeginner YogaBelly DancingChair YogaChant/Kirtan/MusicEvents/Retreats/WorkshopsFeldenkrais Awareness Through MovementGentle YogaIntermediate YogaMartial ArtsMassageMeditationMen's YogaNutrition/AyurvedaOutdoor/Rib Mountain YogaPilatesPrenatal/Postnatal/Family YogaPrivate YogaSound TherapyStrength Training YogaStress Relief YogaTai ChiTherapeutic YogaYoga Philosophy & Sutras StudyYoga Teacher Training
Should be Empty:

5 Koshas LLC