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Private Yoga Session Questionnaire
Once you fill out the form before, please allow 24-48 hours for a response to schedule a session.
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* Indicates required question
Name:
*
Your answer
Email:
*
Your answer
Phone:
*
Your answer
Address:
*
Your answer
Age:
*
Your answer
Height & Weight:
*
Your answer
Occupation:
*
Your answer
Rate your Digestion:
*
Poor
1
2
3
4
5
Excellent
Rate your Breathing:
*
Poor
1
2
3
4
5
Excellent
Are you a nose or mouth breather?
*
Nose breather
Mouth breather
Asthma?
*
Yes
No
High or low blood pressure?
*
Yes
No
Current perceived stress level:
*
High
Moderate
Low
How well do you sleep?
*
Badly
Well
Very Well
On average, how many hours of sleep do you get each night?
*
Your answer
Previous yoga experience:
*
None
Some
Frequently
Prior or current injuries/heath conditions (if none, write N/A)
*
Your answer
What goals do you have for your yoga practice?
*
Your answer
Emergency Contact (Name, Relationship & Phone):
*
Your answer
Additional Comments:
Your answer
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