Confidential Client Information Form

Please fill out the form below, to participate in one of our sessions.

How did you hear about me? Reference

Do you practice yoga?

Yes

Used to do

If yes, how many times a week?

How long have you been practicing?

how long a day?

Constantly | On and off

Describe what type of yoga?

What bring you to the session/package?

Do you exercise or sports?

Yes

If yes, what exercise/sports do you do currently?

How many times a week?

how long a day?

Describe how you feel about it.

Are you on a particular diet?

Yes

If yes, what kind of diet are you in currently?

How long ?

Do you smoke?

Yes

Do you drink alcohol?

Yes

If yes to any of the above, please describe.

Do you have any injuries, surgeries, pains and/or medical conditions?

Yes

If yes, please describe .

Are you currently under doctors care?

Yes

If yes, explain current guidelines and any restrictions

Do you have any metal, dental/breast implant or medical devices inside of your body?

Yes

If yes, explain what and location?

Are you pregnant?

Yes

If yes, which trimester?

Provide a clean quiet environment. For online service, using ear buds wrould be a option! Floor/ground space at minimum of the size of a yoga mat with room to walk around the space. For online service, set up your camera to show your whole body clearly.
Recommend to abstain from alcohol and any recreational drugs ideally within 48 hours of session. If you have questions, contact us. The session might need to be rescheduled.
Client wouldn't have a big meal within 2 hours before the session. Recommend to drink a glass of water.
Wear something comfortable to move.