Yoga Health Intake Form

Name *

First

Last

Email *

Phone Number

Have you practiced Yoga before?

Yes
No

If yes, for how long?

Have you ever had whiplash or any other neck injuries?

Yes
No

Do you get light headed or dizzy when exercising?

Yes
No

Do you have high or low blood pressure?

High
Low
Normal

Do you suffer from back pain? or have had a back injury?

Yes
No

If yes, please explain

Do you suffer from insomnia?

Yes
No

Do you have a bone or joint problem? (such as arthritis, bursitis, osteoporosis) that has been aggravated or might be made worse by excercise?

Yes
No

If yes, please explain

Do you suffer from diseases of the heart, lungs, kidneys, and/or liver?

Yes
No

Are you pregnant?

Yes
No

If yes, how far along?

Are you on any medication?

Yes
No

If yes, please explain.

Do you suffer from a hernia?

Yes
No

If yes, please explain.

Please explain any other health concerns you should share with your instructor

ACKNOWLEDGEMENT & WAIVER (type name below)

I declare the above information to be accurate and true. I acknowledge that I understand that Yoga is not a medical procedure, and the yoga Teacher will not be providing a diagnosis of any medical problems or concerns that I may have. I understand that Yoga is a process of integration intended to facilitate wholeness, body-awareness and self-awareness. I also understand that I am solely responsible for my health, safety and well-being. I agree that I will inform the Yoga Teacher of any activity or movement which I cannot safely perform, and that I will not perform any activity or movement, which I feel is likely to cause me to injure myself. I agree to hold the Yoga Teacher, the Studio or Facility, and the South Okanagan Yoga Academy harmless from any and all responsibility for any injury which I may sustain during or as a result of my Yoga sessions.