Client History

* Indicates required field

Name *

First

Last

Date of birth *

Age *

Phone number *

Email *

What is your assessment of your present condition of health? *

Are you currently under a doctor’s care? If so, please explain. *

For women, are you pregnant? If so, how many weeks? *

Do you have any difficulties with digestion or elimination? If yes, please give specifics: *

Where is tension most evident in your body? (examples: neck, shoulders, feet, stomach, upper or lower back, left side, right side, etc.) *

How did you find out about me? Please give name if referral so I may thank them for introducing us. *

For women, are you using an IUD? *

Yes No

During class I give gentle, hands-on adjustments to help with alignment or, if appropriate, deepen a pose. Do you allow me to assist you in this way? *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

List other therapies besides conventional medicine in which you are currently participating. *

Are you taking any medications? If so, what? *

List previous major illnesses, accident, surgeries or broken bones. *

Why are you trying yoga? *

Do you have diabetes? *

Yes No

Do you have a history of blood clots? *

Yes No

Please list any known allergies *

The creative partnership of mind and body is increasingly recognized by many professionals. Sharing goals can assist in the process of clarifying and enhancing your relationship to them. Yoga serves as an additional support and resource for interfacing the creative mind energy with the body wisdom. Please share about your present goals or desires: this can include your health and other aspects of your wellbeing including work, vocation, creative pursuits, travel, professional and personal relationships *

I agree to receiving marketing and promotional materials

Submit

CLIENT HISTORY