Koochie K Yoga
Yoga Client Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health History
Please check any conditions you currently have or have had in the past:
*
High blood pressure
Low blood pressure
Asthma or respiratory issues
Recent surgery (past year)
Joint issues (e.g., knees, hips)
Back or neck pain
Herniated disc
Arthritis
Osteoporosis
Migraines
Pregnancy (current or recent postpartum)
Other
Other (please specify):
Are you currently under the care of a physician or therapist?
*
Yes
No
If yes, please explain:
Do you take any medications that affect your physical activity?
*
Yes
No
If yes, please list:
Experiences & Preferences
Have you practiced yoga before?
*
Yes
No
If yes, what styles or for how long?
What are your goals for practicing yoga?
Stress relief
Flexibility
Strength
Pain relief
Mindfulness/meditation
Spiritual growth
Other
Do you have any physical limitations or areas you'd like to avoid?
*
Are you comfortable with hands-on adjustments during class?
*
Yes
No
Please ask first
Do you prefer:
A slower, restorative practice
A moderate, balanced flow
A more intense, active session
Doesn't matter
Consent & Release
I understand that yoga includes physical movement, breathwork, and relaxation techniques. As with any physical activity, the risk of injury is present. I affirm that I am responsible for listening to my body, modifying movements as needed, and informing the instructor of any limitations. I hereby release the instructor from any liability for injuries sustained during class.
Signature
*
Today's date:
*
-
Month
-
Day
Year
Date
Submit
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