Yoga Client Intake Form - Confidential Information
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$10 Annual Membership Paid
Today’s Date: _______________
YOGA CLIENT INTAKE FORM - CONFIDENTIAL INFORMATION
WELCOME! We would like to make your yoga experience at BlissBlissBliss as effective and
enjoyable as possible. If at any time you have questions regarding your session, please let us know.
____________________________________________________
Name
Date of birth _____________________
Address ________________________________________________________________________________________________
City, State, Zip ____________________________________________________________________
Home Phone: _______________________ Cell Phone: ________________________ Work Phone: ______________________
____________________________________________________________________
Email Address
Occupation ___________________________________________________________
___________________________________________________________
Emergency Contact (name, #)
Referred by (Name, Flyer, Ad, website, etc.): __________________________________________________________________
YOGA EXPERIENCE/GOALS
Have you practiced yoga before? ____ No ____ Yes (date of last class/practice_______________________________)
How often do you practice yoga? (circle one)
DAILY
WEEKLY
MONTHLY
Style(s) of yoga practiced most frequently:
(circle all that apply)
Hatha
Ashtanga
Vinyasa/Flow
Iyengar
Power
Anusara
Bikram/Hot Forrest
Kundalini
Gentle
Restorative
Yin
Other:___________________________________
What are your goals/expectations for your yoga practice? What benefits are you looking for?
(circle all that apply, explain)
Strength training
Flexibility
Balance
Stress relief
Address health concern
Alternative therapy
Improve fitness
Weight management
Increase well-being
Injury rehabilitation
Positive reinforcement
Other/ Explain:________________________________________________________________________________________
Personal Yoga Interests:
(circle all that apply)
Asana (postures)
Pranayama (breath work)
Meditation
Yoga Philosophy
Eastern energy systems
Other: ______________________________________________________________________________________________
LIFESTYLE & FITNESS
How do you rate your current level of activity?
(circle one)
Sedentary/Very inactive
Somewhat inactive
Average
Somewhat active
Extremely active
On a scale of 1-10,
how would you rate your level of stress
(1 is lowest, 10 is highest)
? 1 2 3 4 5 6 7 8 9 10
**Continued on other side**
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