First Name |
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Last Name |
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Date of Birth |
MM/DD/YYYY
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Gender |
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Marital Status |
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National ID Card or Passport No. |
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Nationality |
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Occupation |
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Phone |
Your primary contact number
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Email |
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Address |
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City |
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State |
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Country |
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Zip Code |
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Emergency Contact Phone |
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Emergency Contact Relationship |
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How did you hear about us? |
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Name of person who referred you |
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Have you practised Yoga before? |
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If Yes, Where? How long & which style? |
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Do you practise Yoga for |
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What is the current state of your health? |
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Tick all major ailments or injuries you are suffering from |
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If Yes, give ailment details |
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Have you recently followed any treatment or been pregnant? |
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If Yes, give treatment/pregnancy details |
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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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Do you want to receive our newsletter and occasional announcements? |
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