Yoga Consultation Form Yoga Intake Form Name * First Last * Last Preferred Pronouns She/Her/HersHe/Him/HisThey/Them/Theirs Phone * Email * Date of Birth Sex * FemaleMalePrefer not to disclose Have you practiced yoga before? Yes No Occasionally What's your reason for exploring yoga? * Describe your current physical activity * Check all that apply Autoimmune disease Allergies/sinus Aneurysm Arthritis Back pain Cancer Constipation Depression/anxiety Diabetes Digestive problems Dislocation Fractures Headaches Heart disease High/low blood pressure Joint problems Kidney/Bladder Knee pain Liver/Gallbladder Menstrual problems Open wounds/cuts Osteoporosis Pregnancy (due date) Recent surgery Stroke Tooth/jaw pain OtherOther Terms of Service * I accept and agree to the statement below The information submitted is confidential. It is understood that yoga is not meant to formally diagnose or treat any illness, disease, or any other physical or mental disorder, injury, or condition. I have informed my instructor about my state of health and have shared any recommendations and restrictions on the part of my medical doctor or therapist. If you are human, leave this field blank. Submit
