Yoga Client Intake Form & Liability Waiver
Welcome! Click on the down arrows to open sections. Please fill in this form as completely as possible to make your yoga experience effective and enjoyable! All information will be kept confidential.
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.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Yoga Experience & Goals
Have you practiced yoga before?
Yes
No
If yes, how often do you practice yoga?
Daily
Weekly
Monthly
What are your goals/expectations for your yoga practice? What benefits are you seeking? (Check all that apply.)
Strength
Flexibility
Balance
Stress Relief
Improve Fitness
Weight Management
Increase Well-Being
Address a Specific Health Concern (explain below)
Injury Rehabilitation (explain below)
Other
Other/Explain
What interests you personally in yoga?
Asana (poses)
Pranayama (breath work)
Meditation
Yoga Philosophy
Other
Other/Explain
Lifestyle & Fitness
Sedentary
1
2
3
4
Very Active
5
1 is Sedentary, 5 is Very Active
On a scale of 1-10, 10 being 'very stressed,' how would you rate your current level of daily stress?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
Please review the following list and check any health conditions that apply to you recently or in the past. This information will be kept confidential.
Anemia
Anxiety
Arthritis
Asthma/Shortness of Breath
Auto-Immune Condition (fibromyalgia, chronic fatigue, Lupus, etc.)
Back Pain/Injury
Broken/Dislocated Bones
Cancer
Depression
Diabetes (Type 1 or 2)
Disc Problems
Heart Conditions/Chest Pain
High Blood Pressure
Knee Pain/Injury
Low Blood Pressure
Muscle Pain/Strain/Sprain
Muscle Weakness
Numbness/Tingling (anywhere)
Osteoporosis
Scoliosis
Seizures
Stroke
Surgery
Other
Other/Explain
Are you pregnant? (Please note that knowing this information is important for me to keep you and your baby safe during your yoga practice. As with the rest of the information on this form, this information will be kept completely confidential.)
Yes
No
If pregnant, what is your estimated due date?
-
Month
-
Day
Year
Date
A Note About Respiratory & Other Contagious Illnesses
Although I no longer have official protocols for COVID-19, I do think it is important to remember that yoga class is meant to be a safe space for all who attend. RSV, Influenza, and COVID-19 are all illnesses that can pose serious concerns for at-risk populations and we never know if the person on the mat next to us may be carrying our illness home to a compromised loved one. If you, or someone in your home is sick with something that is possibly contagious, please consider those who will be in class around you and stay home. Your consideration for the health of your fellow classmates and their friends and family is truly appreciated. Thank you.
Signature
I am so excited to welcome you as a yoga student. The above information is a lot, but it will help you get the most from your yoga practice. Yoga is more than just physical exercise, as it integrates the body and mind to help one relax. However, it is exercise and all exercise programs involve a risk of injury. By choosing to sign, you have voluntarily assumed a risk of injury. “I authorize the collection and use of the above personal information as is required for therapeutic treatment and related administrative purpose. I understand that all my personal information is confidential and will not be released without my signed consent. I represent and warrant that I am in good physical health and do not suffer from any medical conditions that would limit my participation in the classes offered by Heather L. Joyce. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of the yoga classes offered by Heather L. Joyce. I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I understand the risks associated with the activities offered by Heather L. Joyce and I agree to follow all instructions so that I can safely participate in yoga. I acknowledge that participation in yoga classes or any other fitness exercise classes exposes me to possible risks of personal injury. I am fully aware of these risks and hereby release Heather L. Joyce and Amber Niedermaier of all liability, negligence, or other claims arising from, or in any way connected with my participation in their yoga classes and any other exercise classes offered by them. In addition, I will make my yoga instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Heather L. Joyce.”
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Month
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Signature
Date
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Month
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