Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Have you practiced yoga before?

No

Yes

Date of Last class/practice

MM

DD

YYYY

How often do you practice yoga?

Daily

Weekly

Monthly

Other

Style(s) of yoga practiced most frequently: (check all that apply)

Hatha

Ashtanga

Vinyasa/Flow

Iyengar

Power

Anusara

Bikram/Hot Yoga

Forrest

Kundalini

Gentle

Restorative

Yin

Other

Personal Yoga Interests: (check all that apply)

Asana (postures)

Pranayama (breath work)

Meditation

Yoga Philosophy

Other

How do you rate your current level of physical activity?

Sedentary/Very Inactive

Somewhat Inactive

Average

Somewhat Active

Very Active

Are there any health concerns we should know about?

Yes

No

Are you currently taking any medications?

Yes

No