Restorative Yoga Intake Form

Are you a new Yoga client? ALL new clients must submit the following form BEFORE your first session.

The data you provide is strictly confidential. It will never be shared or sold and is used for information purposes only.

Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Country

(###)

###

####

Date of Birth

YYYY

Sex

What are your health goals?

Do you practice any form of yoga or meditation? If so, what type of yoga or meditation do you do, how often, and how long have you been practicing?

Are you physically active? If so, list your activities, duration, and how many times a week you participate in that activity

What is your occupation?

What times do you usually eat your main meals?

Rate your stress levels from 1‐10, with 10 being the highest

Rate your anxiety levels from 1‐10, with 10 being the highest

Do you take any supplements or medications? List them with the dosage

Are you, or have you seen any other practitioners to address your health concerns? Please provide details

Have you ever been diagnosed with a mental health disorder? If yes, please provide details

Have you ever been diagnosed with a disease or other health ailment? If yes, please provide details

Women, are you

Pregnant

Menopausal

Have irregular periods

Agreement

I also understand that

Payment is due upon the completion of the scheduled service by cash or Visa, Mastercard or American Express ONLY

All payments are non-refundable or transferrable for any reason, including, but not limited to vacation, illness and injury

You must cancel a session at least 24 hours before the scheduled service. Sessions cancelled after this time are subject to the full fee

The scheduling and content of activities may be changed on occasion.

I will notify instructors immediately of any pain and/or major discomfort felt during any activity.

If I am pregnant or plan to become pregnant during course of the Activity, I will submit a ParMED-X for Pregnancy, a guideline for health screening prior to participation in a fitness class.

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well‐being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine, This statement is being signed voluntarily. BY SIGNING BELOW, Participant accepts and agrees to the terms and provisions contained in this agreement.

Please type your full name below. This constitutes as your signature.

Today's date

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