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Required for All New Students

1 

Emerald Elephant Yoga required all new students or students who have not practiced at the studio in over 1 year complete this intake form.  Please take amount to complete the form.  Your information will remain confidential. 

2

Our intake form ensures we can best support your yoga practice,  It allows us to understand your unique needs, including any injuries or limitations you may have, so we can tailor the class to safely accommodate you and maximize your benefits.

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General Intake Form

Contact Information

Multi-line address
Birthday
Month
Day
Year

General Information

Please rate your stress level.
1 - No Stress
2 - Low
3 - Moderate
4 - High
5 - Extremely High
Have you practiced yoga before?
What kinds of classes have you practiced? (Check all that apply)

Health Information

Are you currently seeing a doctor for any reason?
Yes
No
Do you have any difficulty getting up and down from the floor?
Are you currently pregnant?
Health History (Check all that apply)

General Release

It is my choice to take a yoga class, workshop, or instruction at Emerald Elephant Yoga. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update Emerald Elephant Yoga of any changes to my health status. I understand that practitioners at Emerald Elephant Yoga do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe pharmaceuticals or medical treatment. I acknowledge that theses sessions are not a substitute for medical examination, diagnosis, or treatment and that it is recommended I see a primary health care provider for those services. I understand I alone am responsible for informing my primary healthcare provider that I am receiving these sessions and inquiring as to whether they may adversely affect my current health condition.

Intake Form

©2023 by Emerald Elephant Yoga.

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