Client Inquiry

Your Name

Date of Birth

Phone Number

Email Address

Address

Have you ever attended a yoga class or worked with a Yoga Therapist?
Private ClassGroup ClassNone

When was the last time you practiced yoga?
This weekLast weekLast Month3 - 6 monthsMore than 6 monthsNever

Have you had a physical exam in the past year?
YesNo

Physician Contact (Name/Address/Phone)

Do you work with a chiropractor?
YesNo

Chiropractor Contact (Name/Address/Phone)

Please indicate if you are taking medication for any of the following conditions:
High Blood PressureDiabetesCancerAnxietyDepressionInsomniaGastrointestinalMigraine/HeadacheVitaminsN/AOther

 

If "Other", please list.

Why are you seeking yoga therapy?

Please indicate any forms of alternative care you have used.
(Ex: massage therapy, aromatherapy, reiki, etc.)

Are you interested in nutritional counseling?
YesNo

Please add any other pertinent information you would like us to know.