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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)!
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:
High/Low Blood Pressure
Hip/Leg Pain or Injury
Knee Pain or Injury
Low Back Pain
Neck Pain or injury
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.
"Breathing in, I am aware of my heart. Breathing out, I smile to my heart. I vow to eat, drink and work in ways that preserve my health and wellbeing." ~Thich Nhat Hanh
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