YOGA IS HEALTH CLIENT REGISTRATION FORM Name * First Name Last Name Email * Phone * Country (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency contact * ph. * Country (###) ### #### What is your main motivation to practice yoga / meditation? * Are you new to Yoga & Meditation? Yes, I am a beginner I've tried it on and off but do not have a regular practice I practice regularly and want to delve deeper into the practice Are you participating in any exercise program ? If yes, what does it involve? * Rate your level of stress Low Middle HIgh Extreme Have you been treated or are you being treated for any of the following? * Heart conditions Respiratory conditions Spinal Injuries Muscle or bone injuries Cancer Blood Pressure Fertility issues Depression PPD or PTSD None of the above Other (Please specify below) Detail of Health Condition * Have you ever had any of these therapies? Naturopathy / Homeopathy / Kinesiology Massage / Shiatsu / Acupressure Chinese Medicine / Ayurveda Physiotherapy / Chiropractic Reiki / Other energy work Are you on any medication or supplements that affect your capacity to exercise? If yes, please state known effects * How did you find out about us? Terms & Conditions I fully understand the terms and conditions provided to me and have answered the questions above to the best of my ability and with this understanding, I electronically sign this form: Thank you!
