Yoga Intake Form

Providing the following information will be most helpful for me in assisting and guiding you through a safe and mindful yoga practice. I sincerely hope that you will enjoy the benefits of my class(es)!
Date of Birth
(Not used for any promotional purposes or spam)
Have you ever studied/practiced yoga before?
If YES, for how long and is there a particular style of yoga you are familiar with or prefer?
Please check any current areas of concern regarding your health:
Please list any conditions (past or present) not listed above and elaborate if appropriate:
Please list any medications, remedies, and treatments used:
Do you participate in any physical activities or sports?
What are your special interests?
I understand that this form does not claim to treat any of the conditions listed above.
By submitting this form, I release Rebecca Kelly from any liability that may occur as a result of the yoga program. Yoga instructions are in no way intended as a substitute for medical counseling.