Thank you for taking the time to fill out this New Client Form to help me better understand your health background and yoga wellness goals.

Name *

First

Last

Email *

Phone Number

Do you currently pracitce yoga? If so, what style and how often do you practice? *

My yoga skill level can be described as: *

• I have never tried yoga
• I know a thing or 2
• I practice regularly

What aspects of yoga are most appealing to you?

• physical postures
• strengthening
• balance work
• relaxation
• meditation
• breathwork
• yoga philosophy
• self care
• yoga lifestyle tips

On a scale from 1 – 10, how physically active is your lifestyle? (10 being the most active) *

What other forms of movement/exercise do you do? *

Do you have any health issues or mobility issues are likely to cause you concern when practicing yoga? *

Do you suffer from any of the following health issues?

• Arthritis
• Asthma
• High blood pressure
• Low blood pressure
• Diabetes
• Ear issues
• Eye issues
• Epilepsy
• Hearth conditions
• Migraines
• Headaches
• Back Pain
• Knee Pain
• Neck Pain
• Recent fractures/sprains
• Anxiety
• Depression

Is there anything else you'd like me to know?

Would you like to receive the CYW Newsletter?

• Yes
• No

Submit

Thank you for taking the time to fill out this form, I appreciate your time.