Yoga Intake Form

Name

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Emergency Contact: Name & contact #

Referred by

Any pets

Occupation

Age

This intake form is for my eyes only. Please only fill out what you are comfortable answering. These questions are meant to offer me more insight in order to better serve you.

Statement of Purpose/Reason for coming in

Patient goals and desired outcomes

Have you experienced any health problems or challenges in your life?

What has your experience with yoga been thus far? Do you currently partake in any yoga practices? If so, what are they?

Based on the answer above, have there been certain practices that you found the most beneficial? Equally, have there been some that were the most challenging?

What is your current level of fitness/physical activity: Sedentary/non-active Somewhat inactive Average Somewhat active Extremely active

Please feel free to provide any other information you feel is relevant

By choosing to participate in today's yoga session and follow-up sessions, you understand there are risks to any physical activity and affirm that you are responsible for your personal health and well-being. I agree to inform my yoga instructor of any activities or movements, which I feel could cause further injury to my condition. I understand that yoga may not always be recommended for certain medical conditions. I agree to listen to my body and monitor myself during each session. I have consulted with my medical practitioner before participating in this program. Adrienne Hite, c r e a t i v e A f f e c t shall not be held liable for any injury, loss, or damage to property and/or persons sustained during or as a result of participation in this yoga session and/or recommended. Cancellations require a 24-hour notice in order to not be charged for the session. Paid sessions are non-refundable and expire one year from purchase date.

Client Signature

Date