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Private Yoga Session Questionnaire
The information provided in this form is for Shannon Kassoff's use for private yoga sessions only. Please fill it out as thoroughly as possible.
Current Date: *
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First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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Email *
Your answer
Phone Number *
Your answer
What is your prefered method of contact? *
Please select all that apply
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Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Have you done yoga before? *
If yes, what styles? *
Please select all that apply
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How many years have you been practicing yoga, and on average, how often?
Your answer
On a scale of 1-10, how physically active is your lifestyle currently (10 being the most active)? *
Your answer
What other forms of exercise do you do? *
Your answer
How long have you been doing these other forms of exercise, and how often?
Your answer
On a scale of 1 – 10, how stressful is your job? *
Your answer
What is the reason for requesting a private yoga session? *
Please select all that apply
Required
If you are requesting a private session to deepen your practice or you are a beginner, please list any specific areas of the body you want to focus on or particular postures you want to explore.
Your answer
If you are requesting a private session to address an injury or ailment please describe this injury/ailment with as much information as possible.
Your answer
If you selected "Other", please explain
Your answer
What would you like to accomplish through your yoga pratice? *
Please select all that apply
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Do you have or have you had any of the following: *
Please select all that apply
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Do you have any limitations, previous injuries, or health concerns not listed above? If so, please explain. *
Your answer
Are you currently under the care of a physician? *
Please list any other modalities you are currently utilizing. (ie physical therapy, acupuncture, ayurveda, yoga, pilates, etc)
Your answer
Are you currently taking any medications that would preclude you from practicing yoga? *
On average, how many hours of sleep do you get each night? *
Your answer
How well do you sleep? *
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What is your current perceived stress level? *
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Are you ok with the use of essential oils? *
Please add any further comments, questions, and/or concerns:
Your answer
I agree with the below terms: *
Waiver, Release, and Assumption of Risk: I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I have been checked by my doctor and cleared to practice yoga prior to signing up for private lessons with Shannon Kassoff. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Shannon Kassoff, and any associated yoga studios. I agree to the above policies for private yoga lessons with Shannon Kassoff, E-RYT-500
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Please check each box to show you have read and agree to each policy: *
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