Yoga Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reason for Initial Visit

What are your goals for this session?

Yoga Consent

I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and reef of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated if excercise any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly.Yoga is not a substitute for medical attention, examination, diagnosis or treatment. I understand that Lisa Colosi Warren is not a doctor. Yoga not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against (Lisa Colosi Warren/Ahimsa Wellness).

Are you taking any medications?

If yes, please list name and use:

Are you currently pregnant?

If yes, how far along? Any high risk factors?

Have you had any injuries or surgeries?

Your Doctor and Contact Information

Please indicate any of the following that apply to you.

Explain any conditions you have marked above.

By signing below, you agree to the following.
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Signature

Date

Yoga Intake Form

Medical Information