Name * First Name Last Name Email * On a scale from 1 - 10, how physically active is your lifestyle? (10 being the most active) * Do you currently practice yoga? If so, what style/type of yoga and how often do you practice? * What are your goals and expectations from your yoga class? * Do you have any other health issues that affect your mobility or are likely to cause you concern when practicing yoga? * On a scale from 1 - 10, how stressful is your life/job/ currently? (10 being most stressful) * What is your vision for working with a coach? * What is your main reason for coming to yoga sessions? Exercise Relaxation Stress relief Flexibility Pain relief Meditation Philosophy Spiritual Other The following conditions require specific modifications to your yoga practice. Please tick if any of the following apply to you. If you tick any, please provide further details below. Abdominal disorders Arthritis (osteo/ rheumatoid) Anxiety Back pain/ problems Cancer Depression Heart conditions / disorders High blood pressure Hip problems Low blood pressure/ fainting Knee problems Nerve damage / trauma Osteoporosis Pain, stiffness, swelling Pregnancy / recent pregnancies Broken bones Surgery (in the last two years) Shoulder / neck problems What aspects of yoga are most appealing to you? Physical postures Relaxation Meditation Chanting Breathwork Yoga Philosophy Self care Ayurvedic lifestyle tips Is there anything else you would like me to know? I take full responsibility for my health during yoga classes. I am fully aware of this risk and hereby release Noble Alkhemy (Dee Davis) from any and all liability, negligence or other claims arising from or in any way connected with my participation in yoga classes. Signed: Date: Thank you! I am looking forward to connecting with you on your yoga journey.
