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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)!
Name
*
Date of Birth
Phone
Email
*
(Not used for any promotional purposes or spam)
Profession
Have you ever studied/practiced yoga before?
Yes
No
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:
Asthma
Ankles/Feet
Anxiety
Arthritis
Autoimmune Dysfunction
Bladder
Cancer
Carpal Tunnel
Chronic Fatigue
Diabetes
Depression
Dizziness
Eyes
Gastrointestinal Disorder
Headache
Heart Condition
High/Low Blood Pressure
Hip/Leg Pain or Injury
Hypoglycemia
Insomnia
Kidney Condition
Knee Pain or Injury
Low Back Pain
Menopausal
Multiple Sclerosis
Neck Pain or injury
Osteoporosis
Plantar Fasciitis
Prolonged Illness
Prostate
Recent Surgery
Sedentary Lifestyle
Sciatica
Scoliosis
Shoulder Pain or Injury
Wrist or Hand Pain
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.
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