New student intake and waiver

New Student intake

est. time 3 mins
Name*

First NameLast Name
Select country of residence:*
E-Mail*
example@example.com
Country code+ phone number *
Birth Date*

MonthDayYear
Age*
Height*
Weight*
Emergency contact name*

First NameLast Name
Emergency contact country code+ phone number *
Have you actively practised Yoga in the past ?*

YesNoI have dabbled
List the benefits you are looking for*

StrengthFlexibilityLongevityBalance and stabilityReduce painImprove sleepBe happier and calmerReduce stressImprove postureIncrease metabolismImprove blood circulationWeight loss and maintenanceIncrease muscle toneManage a health condition
Pick the various aspects of Yoga you are interested in*

Postures/ asanasBreath work/ pranayamaMeditationYogic nutritionPositive thinkingLifestyle change, building good habits
Any other reasons for your interest Yoga
Tell us your goals in detail
If you are currently practising Yoga, details of the type and frequency of Yoga you are currently practising
Eg. hatha, ashtanga, iyengar, hot yoga etc.
How many days per week are you able to commit to practising Yoga?*

1-2 times per week3-5 times per week
Exercise*

Never1-2 days3-4 days5+ days
Details of the type and frequency of any other exercise you do on a consistent basis
consistent means at least 2x per week for the last 3 months
Is your daily routine regular from one day to the next? For example: consistent sleeping and eating times *
What is your sleep quality?*
What is your general state of mind?*
Health History

Gastrointestinal:
Check all that apply currently*

ConstipationIBSBloating and gasHaemorrhoids, Piles or Anal FissuresAcidity & GERDMigraineNone

Cardio vascular system:
Check all that apply currently*

Low blood pressureLow blood pressureCoronary heart disease/ Ischemic Heart DiseaseIrregular heart beatVaricose VeinsStrokeFacial ParalysisNone

Autoimmune:
Check all that apply currently*

Rheumatoid Arthritis (RA)Ankylosing SpondylitisNoneOther

Female Reproductive System:
Check all that apply currently*

Dysmenorrhea (painful periods)PMS (Pre Menstrual Syndrome)Polycystic ovary syndrome (PCOS)FibroidsGoing through menopauseNone

New Student intake