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Private Yoga Intake Form
Intake Form
Personal Information
*
Indicates required field
Full Name
*
Address
*
Email
*
Phone Number
*
Age
*
Occupation
*
Emergency Contact
*
Name and Number
Referred by
*
Client Referral / Friend
Social Media
Advertising
Website
Publication / Article
Yoga Experience
Have you practiced yoga before?
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No
Yes
How often do you practice yoga?
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N/A
Daily
Weekly
Monthly
What styles of yoga do you normally practice?
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Ashtanga
Vinyasa Flow
Restorative
Yin
Iyengar
Rocket
Power
Bikram/Hot
Hatha/Gentle
Yoga interest
*
Asana (physical practice)
Pranayama (breath work)
Meditation
Yoga philosophy
Other Interest
What do you want to achieve from private classes?
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Strength training
Flexibility
Balance
Stress relief
Address health concern
Alternative therapy
Improve fitness
Weight management
Enhance well-being
Injury rehabilitation
Positive reinforcement
Other reason
Lifestyle and Health
Please review this list and select those conditions that have affected your health either recently or in the past.
*
Broken/dislocated bones
Diabetes type 1 or 2
Pregnancy
Muscle strain/sprain
High/low blood pressure
Surgery
Arthritis, bursitis
Insomnia
Seizures
Disc problems
Anxiety/depression
Stroke
Scoliosis
Back problems
Asthma/short breath
Cancer
Osteoporosis
Heart condition/chest pain
Numbness, tingling anywhere
Auto-immune condition
What is your current level of fitness?
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Very inactive
Fairly inactive
Average
Fairly active
Very active
How would you rate your level of stress?
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1
2
3
4
5
6
7
8
9
10
1 is lowest, 10 is highest
If any of the information on this form needs further detail, or if there is anything else to share, please do so:
*
Please read the following information and accept below.
I am delighted to welcome you as a yoga student at Yogivibesaruba. The following information will help you get the most out of your yoga classes and clarify the instructor/student relationship.
I believe that Yoga is more than physical exercise. It is a transformative practice that integrates body, mind and emotional tensions to arrive at deeper levels of relaxation and awareness. As with any physical activity there is a risk of injury associated with yoga.
The decision to perform any exercise is down to the individual, and Yogivibesaruba cannot accept responsibility for problems during or outside a class. The participant agrees to take on full responsibility for their actions within the class and shall work within their own limits. If students have any inquiries or health concerns it is their responsibility to notify the instructor so that she is aware of your limits. If you are in doubt as to your fitness, please consult your physician beforehand.
Yogivibesaruba shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in this class. I agree to listen to my body and monitor myself during every class session. I agree to the Terms and Conditions
as stipulated by Yogivibesaruba, including the cancellation policy.
I agree
*
Yes
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