Zen Lab

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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

Address

Occupation

Have you practiced yoga before?

Yes

On a scale 1-10 (10 being highest), how would you rate your level of daily activity?

Phone

Emergency Contact

How often do you practice yoga?

On a scale 1-10 (10 being highest), how would you rate your level of daily stress?

Other/explain

Are you currently taking any medications?

Yes

If yes, please list the names and reasons for medications.

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 Zen Lab. 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 post-natal 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 Zen Lab.