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BALANCING LIFE YOGA Registration Form - Group Class (Not Prenatal) Name ____________________________________________________________ Address __________________________________________________________ City _________________________ State ________________ Zip ____________ Phone (h) _________________ (c) __________________ DOB (month/year)______ E-mail address(es) __________________________________________________ Do you want to be on our mailing list? YES______ No _____ How did you hear about us? __________________________________________ Referred by _________________________________________ Do you have any previous yoga experience? Yes __ No __If yes, what kind? __________ Do you have any ailments or physical limitations? _______________________________ Back or neck concerns? ___________________ If back which part? _________________ Hip or knee problems? _____________________________________________________ Have you had surgery within the last year? ____________________________________ RX Medication? _____________________________________ ACE inhibitors? ________ Are you pregnant? _________ How far along ? ______________________ Do you currently follow any exercise program? _________________________________ Which benefits of yoga are the most important to you? Improve posture ______ Improve strength ______ Improve balance ______ Increase flexibility _____ Manage Stress ________ regulate breath _______ Strength immune system ______ Improve circulation and digestion _______ Promote Deep Relaxation ______ Help Manage: Depression _____ Anxiety ______ Other? ________________________________________________________________ Page 1 of 2 Buyer/participate is aware that participation in a physical activity may result in accident or injury. Buyer/participate assumes the risk associated with the participation in any exercise and represents that member is in good health during their participation in a Balancing Life Yoga Class or use of any Balancing Life Yoga equipment or use of any facility where Balancing Life Yoga is hosting its class(es). Buyer/participate acknowledges that Balancing Life Yoga has not and will not render any medical services including medical diagnosis. Buyer/participate specifically agrees that Balancing Life Yoga, it's officers, employees and agents shall not be liable for any claim, demand or loss of any kind resulting from Member's/participate's use of any Balancing Life Yoga equipment, facility where Balancing Life Yoga is holding its class(es) or participating in any Balancing Life Yoga exercise or activity. Buyer/participate agrees to hold Balancing Life Yoga harmless from same. Signature __________________________________________ Date_____________ Print Name ___________________________________________________________ Emergency Contact ___________________________________ relationship _____________ phone number ________ BALANCING LIFE YOGA Registration Form - Private Clients & Prenatal This form is an important tool to help me design a safe and appropriate yoga program for you. Thank you for taking the time to Address __________________________________________________________ City _________________________ State ________________ Zip ____________ Phone (h) _________________ (c) __________________ DOB (month/year)______ E-mail address ________________________________ Do you want to be on our mailing list? YES______ No _____ How did you hear about us?__________________________________________ Referred by _________________________________________ Do you have any previous yoga experience? Yes __ No __If yes, what kind? ______________ Do you have any ailments or physical limitations? ___________________________________ What is your height_________ What is Your weight____________ Do you smoke? ________ Neck concerns? _____________________ Neck surgery? ____ If yes, when_______________ What kind?__________________ Cervical Fusion? _____if yes,where? C? C?____________ Have you been released for exercise?_____ If yes, when?______________________________ Back concerns? ____________________________which part? _________________________ Back surgery?_____ if yes, when ____________ what kind?____________________________ Lumbar surgery? ________If Lumbar surgery where? L?-L? _______________ If any back surgery, have you been released for exercise? _____ If yes, when______________ Page 2 of 3 - Balancing Life Yoga, LLC - Private Client - Registration Form - Initials of Client ______ Hip concerns? __________________________________________Right or Left?___________ Hip surgery?_____ if yes, when ____________ what kind?_____________________________ If any hip surgery, have you been released for exercise?_____ if yes, when________________ Knee concerns/Injuries? ____________________________________Right or Left?________ Have you had any type of knee surgery within the last year?_____ If surgery, when ________ If surgery, what kind?______________________________________ If any knee surgery, have you been released for exercise?_____ if yes, when_____________ Pregnancy:Are you pregnant? ______ How far along ? __________________________ Have you had a C-section in the last year?______ If yes, how when?_____________ If you have had a pregnancy in the last year, have you been released for exercise? ________ If yes when?____________ If you are pregnant, have you consulted your doctor about taking yoga? _______ ; If pregnant, do you have permission from your doctor to take yoga?________ Do you have any of the following: Glaucoma?__________ if yes, is it Narrow Angle Glaucoma ___________
If yes, what was your last bone density level (results) ______________ Scoliosis_____ If yes, is it "C" or "S" shape? _____ If yes, is it Thoracic, Lumbar or Thoracolumbar______________________________________ Low blood pressure/hypotension? ____________ if yes, is it under control?_______________ High blood pressure/hypertension? ___________ if yes, is it under control? ______________ RX Medication? _____________________________________ ACE inhibitors? (yes/no)______
If you have any other medical condition I should know about please list it/them here:
Do you currently follow any exercise program? _____________________________________ Page 3 of 3 - Balancing Life Yoga, LLC - Private Client - Registration Form - Initials of Client ______ What kind of hobbies do you do or enjoy? _________________________________________ Which benefits of yoga are the most important to you? Improve posture ______ Improve strength ______ Regulate breath _______ Improve or Increase flexibility _____ Strengthen immune system ______ Improve circulation and digestion _______ Promote Deep Relaxation ______ Help Manage: Depression _____ Anxiety _____ Stress _____ Improve Sleep _____ Improve Self Esteem _____ Learn an additional or alternative spiritual view_____ Learn an alternative view of medicine and psychology _____ Other?
Buyer/participant is aware that participation in a physical activity may result in accident or injury. Buyer/participant assumes the risk associated with the participation in any exercise and represents that member is in good health during their participation in a Balancing Life Yoga Class or use of any Balancing Life Yoga equipment or use of any facility where Balancing Life Yoga is hosting its class(es). Buyer/participant acknowledges that Balancing Life Yoga has not and will not render any medical services including medical diagnosis. Buyer/participant specifically agrees that Balancing Life Yoga, it's Signature _____________________________________________ Date_____________ Print Name _________________________________________________________________ Emergency Contact _____________________________________________________ญญญญ_____ Name ______________________________________ relationshipphone number__________________ |
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