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New Yoga Client Intake and Health History Form
Please fill out the following health declaration form in order to participate in our activity.
First Name
Last Name
Email
Address
Occupation
Have you practiced yoga before?
No
Yes
On a scale 1-10 (10 being highest), how would you rate your level of daily activity?
What styles of yoga have your pacticed before?
Ashtanga
Hot Yoga
Bikram
Kundalini
Power yoga
Yin/Restorative
Hatha
Iyengar
Vinyasa
Not Sure
Other
Phone
Emergency Contact
How often do you practice yoga?
Choose an option
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On a scale 1-10 (10 being highest), how would you rate your level of daily stress?
What are your health goals for your yoga practice?
Weight loss/maintenance
Strength building
Stress relief
Flexibility
Improve overall health
Alternative therapy (explain below)
Address specific health concern (explain below)
Balance/inner peace
Vinyasa
Not Sure
Other
Other/explain
Which aspects of yoga are you most interested in?
Physical postures
Yoga philosophy
Breathwork/pranayama
Meditation
Not Sure
Other (explain below)
Other/explain
Please review the following list ad check any health conditions that apply to you or have applied to you recently.
Arthritis
Osteoporosis
Muscle Pain
Scoliosis
Bulging Disc
Degenerative Disc
