Yoga Client Intake

Client Intake

Yoga Class
Name

First NameLast Name
Have you practiced yoga before?

YesNo
How often do you practice yoga? (Check one)

NeverOnce every few weeksOnce a weekA few times a week
What styles of yoga have you practiced before? (Check more than one)

AshtangaHot YogaBikram YogaKundaliniYin/Restorative YogaPower YogaHatha YogaIyengarVinyasa YogaNot sure
What are your health goals for your yoga practice? (check more than one)

Weight loss/maintenanceStrength BuildingStress reliefFlexibilityImprove overall healthAlternative therapy (explain below)Address specific health concern (explain below)Balance/Inner Peace
Explanation for selections note above
Which aspect of yoga are you most interested in? (Check more than one)

Physical posturesYoga philosophyBreathwork/PranayamaMeditation
Please review the following list and check any health conditions that apply to you or have applied to you recently.

ArthritisOsteoporosisMuscle PainMuscle WeaknessScoliosisBulging DiscDegenerative DiscBack pain/injuryAnemiaSciaticDiabetesAsthma, shortness of breathSeizuresStrokeHeart conditions, chest painAnxietyDepressionHigh Blood PressureLow Blood PressureSurgeryKnee Pain/InjuryCancerPregnancy (explain below & estimated due date)
Elaborate on any selections above if necessary.
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 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.
By signing, I affirm that a licensed physician has verified my good
health and physical condition to participate in yoga classes
offered by {insert company name here}. 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 postnatal 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
Rhodes-Pope.
Signature
Date

MonthDayYear
Date
Should be Empty: