Yoga Questionnaire
This form will help Amrit by Bryne Boyer assist you with reaching your Yoga goals.
Email address *
Full Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
Occupation *
Your answer
Age *
Your answer
Height *
Your answer
Weight *
Your answer
Emergency Contact *
Your answer
Emergency Number *
Your answer
How many times per day do you eat? *
Your answer
What are the size of your meals? *
Your answer
Please describe your weekly diet *
Your answer
Rate your digestion *
Good
Bad
Are you a nose or a mouth breather? *
If mouth breather, why? *
Your answer
Asthma *
Blood pressure *
If you have high blood pressure is it controlled with medication? What type? *
Your answer
History of heart disease? *
Your answer
History of anxiety or depression? How long? Medication? *
Your answer
Current perceived stress level? *
Quality of sleep? *
How many hours of sleep do you get per night? *
Your answer
Sitting at desk or driving? *
Standing *
Carry heavyweight? *
Travel by plane *
Please list all current medications and why? *
Your answer
Please list all current exercises and physical activity *
Your answer
Please list team or competitive sports *
Your answer
Please list prior and or current injuries or health conditions and explain. *
Your answer
Most important please list your goals for your practice. *
Your answer
When are the best days and times for you to meet? *
Your answer
Any additional comments or concerns? *
Your answer
RELEASE/WAIVER OF LIABILITY AND AGREEMENT​​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 BRYNE BOYER. I HEREBY AGREE TO IRREVOCABLY RELEASE AND WAIVE ANY CLAIMS THAT I HAVE NOW OR MAY HAVE HEREAFTER AGAINST BRYNE BOYER, THEIR HEIRS, SUCCESSORS OR ASSIGNS. I AGREE TO THE ABOVE POLICIES AND PRICING FOR PRIVATE YOGA LESSONS WITH BRYNE BOYER. *I agree. (Please make sure the form is properly submitted. If required fields are not filled out, the form will not send.) *
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