Therapeutic / Special Needs Intake Form

Your information is confidential.

Name
First Last
Email
Phone
Message to Yoga Shala Directors
Pregnancy (# of weeks)
Joint pain, restrictions, or replacements (give details)
Accidents, injuries, surgeries (with dates)
Pain - Episodic or chronic; nerve, muscular or joint pain
Systemic issues: (immune conditions, movement disorders, chronic fatigue, high blood pressure, etc.)
Brain injuries, perceptual issues (hearing, sight), dizziness
Anxiety, depression, PTSD, etc.
Other diagnoses (cancer, etc.)
Are you able to easily get up and down off of the floor?
In the last year, if you had an accident, surgery, or major medical issue, has you doctor cleared you to attend yoga classes and return to normal activities?
- Yes
- No
Is there anything else that might affect you during a yoga class?