YOGA CLIENT INTAKE FORM

DISCLAIMER: Thank you for your interest in being a client of [STUDIO NAME]. Information collected about new clients is confidential and will be treated accordingly.

STUDENT GENERAL INFORMATION

Name: ______________________________  Date of Birth: _____________
Address: ____________________________ Phone: ___________________
Emergency Contact Name: __________________  -Phone: _______________
Referred by: ___________________________________________________

YOGA EXPERIENCE/GOALS

Have you practiced yoga before? ☐ Yes ☐ No
-If yes, when was your last class/practice? _____________

How often do you practice yoga? ☐ Never ☐ Daily ☐ Weekly ☐ Monthly

What style of yoga have you practiced most frequently? 
☐ Hatha ☐ Ashtanga ☐ Vinyasa/Flow ☐ Iyengar ☐ Power ☐ Anusara ☐ Bikram/Hot
☐ Forrest ☐ Kundalini ☐ Gentle ☐ Restorative/Yin ☐ Other: ___________________

 What are your goals/expectations in yoga? What benefits do you seek? 
☐ Strength training ☐ Flexibility ☐ Balance ☐ Stress relief ☐ Address health concern
☐ Improve fitness ☐ Weight management ☐ Increase well-being
☐ Injury rehabilitation ☐ Positive reinforcement ☐ Other: _______________________

What are your personal yoga interests?
☐ Asana (postures) ☐ Pranayama (breath work) ☐ Meditation ☐ Yoga philosophy
☐ Eastern energy systems ☐ Other: ______________________________________

LIFESTYLE AND PHYSICAL HISTORY

How do you rate your current level of physical activity?
☐ Very inactive ☐ Somewhat inactive ☐ Average ☐ Somewhat active ☐ Very active

On a scale of 1-10, how would you rate your level of stress? _____

Specify any conditions that have affected your health recently or in the past:

Are you currently taking any medications? ☐ Yes ☐ No
-If yes, please list the names and reasons for the medications:

ACKNOWLEDGMENT

Signature: _________________________ Date: ___________
Printed Name: _______________________