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Phone	Your primary contact number
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How did you hear about us?
Name of person who referred you
Have you practised Yoga before?	Have you practised Yoga before? Yes No
If Yes, Where? How long & which style?
Do you practise Yoga for	Do you practise Yoga for Fitness Stress Relief Illness Recovery Spiritual
What is the current state of your health?	Good Average Poor
Tick all major ailments or injuries you are suffering from	Tick all major ailments or injuries you are suffering from Asthma Diabetes Arthritis Bone or Joint problem High Blood Pressure Low Blood Pressure Neck pain Knee pain Back pain Headache None other:
If Yes, give ailment details
Have you recently followed any treatment or been pregnant?	Have you recently followed any treatment or been pregnant? Sought therapy or counselling Had surgery Attended physical therapy Become pregnant None
If Yes, give treatment/pregnancy details
Are you currently under a physician’s care for a specific medical problem? If yes, for what and for how long?
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