Yoga Student Information Form
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1
2Samamkaya Yoga Student Information
Name: ____________________________________________________ Date: _____________
New to yoga? Yes
No
If yes, how long have you studied? __________________________
Occupation: _________________________ Age: _______ Sex:
M
F
Other
Check the areas of concern that apply for you, past and present:
Musculoskeletal
Knees
Other Conditions
Insomnia
Ankles/Feet
Neck
Allergies
Kidney
Arthritis
Osteoporosis
Asthma
Liver
Osteo
Plantar Fasciitis
Anxiety
Lyme Disease
Rheumatoid
Sciatica
Auto-Immune
Menopausal
Back Pain
Scoliosis
Dysfunction
Mental Health
Upper
Shoulders
Bladder Trouble
Concern
Middle
Spinal Fusion
Blood Pressure
Multiple Sclerosis
Lower
(see below)
High
Parkinson’s
Broken Bones
Spondylolisthesis
Low
Pregnancy
Carpal Tunnel
Antero
Cancer
Post-partum
Disc Herniation/
Retro
Chronic Fatigue
Prostate
Condition
Stenosis
Diabetes
Sedentary
Fibromyalgia
Surgery (see
Depression
Skin Condition
Hands/Arms
below)
Dizziness
Surgery (see
Headaches/
Eyes
below)
Migraines
Gastrointestinal
Thyroid
Heel Spur
Disorder
Vertigo
Hips/Legs
Gynecological
Hyper-kyphosis
Heart Condition
Hyper-lordosis
Hypoglycemia
Please describe conditions not listed above, or elaborate those checked ___________________
_____________________________________________________________________________
_____________________________________________________________________________
Please list surgeries ____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If you have a spinal fusion, please list the date of fusion, length of fusion, date of revision surgery
(if applicable), if you have a bone graft and where it came from, and any post-operative treatment:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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