RYC Liability Waiver

Intake Form

Movement Services
Client Information Questionnaire
All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to developing a program that addresses your needs, goals, and interests and is safe and effective.

Personal Information
Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *
Please enter a valid phone number.
Email: *
example@example.com
Occupation: *
Emergency Contact: *
Phone Number: *
Please enter a valid phone number.
Physician's Name: *
Physician's Phone: *
Physician's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Medical Information
Please provide 24 hours notice if you need to cancel or reschedule your appointment.
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *

Yes No
Do you frequently have pains in your chest when you perform physical activity? *

Yes No
Have you had chest pain when you were not doing physical activity? *

Yes No
Do you lose your balance due to dizziness or do you ever lose consciousness? *

Yes No
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? *

Yes No
Are you pregnant now or have given birth within the last 6 months? *

Yes No
Have you had a recent surgery? *

Yes No
Please check all conditions you have encountered throughout your lifetime.
Head/Neck

TMJ/Teeth Grinding Jaw Pain Headaches Neck Pain Heading/Vision Loss Sinus Iifections/Allergies Thyroid Dysfunction Other
Shoulders

Left Rotator Cuff Injury/Pain Right Rotator Cuff Injury/Pain Left Shoulder Impingement Right Shoulder Impingement Left Shoulder Injury/Pain Right Shoulder Injury/Pain Other
Arm/Hand

Left Carpel Tunnel Right Carpel Tunnel Left Tennis Elbow Right Tennis Elbow Numbness In Left Hand Numbness In Right Hand Left Hand Always Cold Right Hand Always Cold Other
Spine/Upper Or Lower Back

Upper Back Pain/Injury Lower Back Pain/Injury Other
Leg/Knee

Left ACL Injury Right ACL Injury Left Cartilage Concerns Right Cartilage Concerns Left Knee Pain/Injury Right Knee Pain/Injury Left Edema (Swelling) Right Edema(Swelling) Left Knee Replacement Right Knee Replacement Other
Foot/Ankle

Left Bunion Right Bunion Left Hammertoe Right Hammertoe Left Plantar Fasciitis Right Plantar Fasciitis Left Numbness In Foot Right Numbness In Foot Left Foot Always Cold Right Foot Always Cold Left Foot Pain/Injury Right Foot Pain/Injury Left Ankle Pain/Injury Right Ankle Pain/Injury Left Edema (Swelling) Right Edema (Swelling) Other
Neurological/Limbic

Alzheimer's Memory Loss Brain Fog Anxiety/Panic Attacks Depression Other
Digestive

Constipation/Diarrea Acid Reflux/Heartburn Diverticulitis Gallstones Unexplained Weight Gain/Loss Other
Respiratory

Asthma COPD Shortness Of Breath Lung Disease Other
Cardiovascular

High Blood Pressure High Cholesterol Stroke Heart Disease Other
Lymphatic

Lymphoma Lymph Node Swelling Breast Cancer Fatigue Other
Organ Functions

Diabetes Kidney Disease Gallstones Appendicitis Liver Dysfunction Adrenal Dysfunction Other
Reproductive/Urologic

Menstrual Cramps/PMS Yeast/Bladder Infections Infertility/Miscarriage Urinary Incontinence Erectile Dysfunction Prostate Issues Kidney Stones Other
Hips/Pelvis

Pelvis Pain/Injury Hip Pain/Injury Hip Replacement Other
Please include information on ANY surgeries (cosmetic, outpatient, injury repair, reconstructive, laparoscopic, etc.), injuries, pregnancies, deliveries, cesareans, etc.
Do you take any medications, either prescription or non-prescription, on a regular basis? *

Yes No
If yes, what is the medication for and how does it affect your ability to exercise?

Please indicate your top 3 goals for your exercise session. *

	Goals
1
2
3

Description of Concerns
Please use this section to describe why you are seeking help from Yoga Heart & Mind LLC / Stephanie Watson Lewis. Include any relevant history or pain, discomfort, surgery and injury. Please also mention any stresses in your life which are above your usual. Please also include any emotional difficulties or anything in your whole body – physical, emotional, social that are of significance.

Participant Release and Knowledge of Agreement
I, Client Name*, wish to participate in the exercise and training program offered by Stephanie Watson Lewis I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that Stephanie Watson Lewis shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Stephanie Watson Lewis from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.

I agree not to hold Yoga Heart & Mind LLC/Stephanie Watson Lewis, or any of its affiliates liable for any injury or damages related to my participation in 1-on-1 sessions, in person classes, online classes, workshops, trainings, retreats or other activities.
I have read and understand this term. *

Yes
I certify that the answers to the questions outlined on the PAR-Q form are true and complete to the best of my knowledge. I acknowledge that medical clearance is required if I have answered “Yes” to any of the questions on the PAR-Q form. I understand and agree that it is my responsibility to inform the instructor of any conditions or changes in my health, now and on going, which might affect my ability to exercise safely and with minimal risk of injury. *

Yes
I understand that I am not obligated to perform nor participate in any activity that I do not wish todo, and that it is my right to refuse such participation at any time during my training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform the instructor. *

Yes
I understand the results of any exercise program cannot be guaranteed and my progress depends on my effort and cooperation in and outside of the sessions. *

Yes
I understand that all private session rates are based on 30 or 50 minute sessions and should I arrive late, there is no guarantee I will receive the full session with the instructor. In return, if the instructor is late for a session, I will still receive the full session time. *

Yes
I understand that Yoga Heart & Mind LLC / Stephanie Watson Lewis operates on a scheduled appointment basis for all personal sessions and thus, requires that I provide 24 hours notice when canceling an appointment. No charge will be levied should I cancel with MORE than 24 hours notice given. *

Yes
I understand that during an exercise session, Yoga Heart & Mind / Stephanie Watson Lewis may have to use Touch Training to correct alignment and/or to focus my concentration on a particular muscle area to be targeted. If I feel uncomfortable or experience any type of discomfort with Touch Training, I will immediately request that the instructor discontinue using this technique. *

Yes
I understand that Yoga Heart & Mind / Stephanie Watson Lewis photographs many of her client events/sessions and I provide written approval for her to use these pictures for promotional purposes. *

Yes
I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.
Signature: *

Clear
Today's Date: *

Month Day Year
Date
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Intake Form

Client Information Questionnaire