Yoga Intake Form

Please PRINT and fill out both sides     

 Name: ___________________________________________           Home: (_____) __________________________
 Address: ___________________________________________        Cell : (_____) __________________________
 Apt. ________ City: _______________________________________   State: _______  Zip: __________________
 E-Mail:________________________________________________   Date of birth _____/_____/____________
     Occupation & Primary activities: _______________________________________________________________  
How did you hear about us: _____________________________________________________________________
In case of Emergency: ____________________________________ Relationship: ___________________________
      Phone: (_____) ______________________  	         Alt Phone: (_____) ___________________________
General Health Questions:

What Level of Yoga experience do you feel you have?
 Circle one     Beginner/Basics       Level 1       Level 2        Advanced        Instructor       YTT   

Medications you currently take: __________________________________________________________________ 
	
Explain: ______________________________________________________________________________________

Have you had any major injuries, illnesses, surgeries or medical issues that occurred or changed in the last two (2) years? This includes any changes to medications, major piercings, sprains, breaks or discomforts. 
Explain: ______________________________________________________________________________________
_____________________________________________________________________________________________
Please list any past conditions that are controlled/managed/healed but still may affect you today and or may affect you in your practice of Yoga, specifically the Yoga Wall. List all and feel free to explain in detail. 
Bones, skeletal or joint issues including joint replacement, grafts or fusions:
____________________________________________________________________________________________
Cardiac problems. Heart attacks, pacemaker, tachycardia, etc.:
____________________________________________________________________________________________
Skin disease, skin allergies, rashes or open sores:
____________________________________________________________________________________________
Continue on reverse side

Cosmetic surgeries, implants, liposuction, etc.:
_____________________________________________________________________________________
Diseases or Syndromes such as fibromyalgia, cerebral palsy, MS, MD, epilepsy, Parkinson’s Disease: 
_____________________________________________________________________________________
Is there anything else you would like us to know before we begin?
_____________________________________________________________________________________
_____________________________________________________________________________________ 
	
	NOTE: Your health is our concern and taken seriously. 
Please read all conditions. See the underlined section for additional cautions/conditions for “Off the Wall” Classes

I understand that Yoga and other movement classes are provide for the basic purpose of relaxation, as well as body, mind and spirit integration. Should I experience pain or discomfort during class, I will immediately inform the instructor so that modifications can be given to adjust instruction to my level of comfort. We also suggest prudency when you are experiencing menstruation, mild headaches, sinus problems, light headedness, low blood pressure or if you get sore more easily as classes can intensify the symptoms of all these. Self-awareness is essential to keep the instructor informed of any discomfort. You may be asked to pause/sit-out or discontinue your practice if the instructor feels at any time harm or injury could result. Postures/stretches may also be limited base on other medical information you supply on the reverse side of this form. Please be accurate so we may be informed of any previous surgeries, injuries, illnesses that could either be re-injured or cause further harm. 

Off the Wall classes: No first trimester pregnancies will be allowed, second and third trimester pregnancies with caution only. Those with spinal Injuries/back or neck pain, headaches, glaucoma, high blood pressure, controlled or medicated high blood pressure, vertigo, or epilepsy (seizures), we advise a doctor’s release before attending any classes. If you otherwise choose to attend, full responsibility is taken by the participant (you) and _____________________________________ will be held harmless and non-liable. Classes of up to 10 are just that, classes, and not to be construed as individual therapy/instruction. If you require individual/private sessions for your ailment / infirmities, this can be set up at additional cost. 

By signing this I agree ___________________________is NOT responsible for any personal injury to any student, or any loss of personal property while attending classes at Spirit of Yoga. I also agree that all the information on these two pages is accurate, informative and I will keep ___________________studio appraised/updated of any changes in the present and future. Minors are welcome with prior consent of their parent or guardian. 

I understand and agree that I further state that I am at least 18 years of age. 

     Signature: ________________________________________ Date: _____________________________

If under the age of 18 please have parent/guardian complete the following:
      Signature:________________________________________ Date: _____________________________
	(Parent and or Guardian: this is required for minors 14 to 17 years of age, thank you for understanding!)

Received by: ___________________________________