Client Intake Form

Name:________________________________________________ Today’s date: ___________

Previous yoga experience: Yes / No How long: __________________________________

Male/Female ___________ Date of Birth _____________ Occupation ____________________

Address: _____________________________________________________ Apt: ___________

City: ________________________________________ State: ___________ Zip: ___________

Phone: ____________________ email: ____________________________________________

Emergency Contact Information

Name: _____________________________________________________________________

Relationship: _____________________________ Phone: ____________________________

Medical Information

Allergic reactions: _____________________________________________________________

Physical limitations: ___________________________________________________________

Pregnant: Yes / No How far along: ________________________________________

Other (eg. asthma, heart condition): _______________________________________________

Referrals

How did you hear about us? _____________________________________________________

Whom may we thank for referring you? ___________________________________________