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Being in Your Body Sign Up Form
Karmic Roots Yoga, LLC
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First Name
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Last Name
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Email
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Date of Birth
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Address
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Phone number
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Emergency Contact & Relationship
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Emergency Contact Phone Number
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Please sign me up for Karmic Roots Yoga Newsletter (you will never receive spam or have your information shared).
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What are your current reasons for joining in this group experience? In other words, tell me about your goal(s) for our time together. What are you looking for from this space?
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How would you describe your spiritual or religious life?
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Do you have any of the following conditions that you would like Paige to be aware of:
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Asthma
Heart/circulatory imbalances
dizzy spells/fainting
pregnancy
high/low blood pressure
diabetes
epilepsy/seizures
Other:
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List your current & previous health conditions. Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates.
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Other medical condition, injury, or disability you would like your instructor to be aware of? (if no, note below)
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Consider your current health concerns. How long has this been impacting you?
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Who else are you currently seeing for your health concerns or general health and wellness? How often do you see them?
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Do you have any doctor prescribed restrictions? If yes, please list them and if no please note this.
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Any Mental/Emotional Health items you would like your instructor aware of? (if no, note below)
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Share any areas of discomfort in your body. Try to describe where they are located and any type/degree of discomfort
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What relieves pain for you? What increases it? (consider movements and range of motion that affect you)
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Where do you feel you hold tension in your body?
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Describe your overall energy level. Does it fluctuate or stay consistent? When are you the most energized? The least?
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How do you perceive the stress levels in your life currently? low, moderate, high, etc.
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Check any of the following emotions that you experience on a regular basis.
Worry
Anxiety/Fear
Overwhelm
Spaced Out
Insomnia
Self-destructive
Indecisive
Check any of the following emotions that you experience on a regular basis.
Irritable
Anger/Rage
Aggressive
Jealousy/Envy
Critical/Judgmental
Intense/Sharp
Tension
Check any of the following emotions that you experience on a regular basis.
Lethargy
Sadness
Depression
Greediness
Over-attachment
Procrastination
Controlling
Considering the prior three questions, are there places in your body where these feelings tend to dwell when they come up? If so, please list.
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What life challenges are your currently facing?
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What aspects of your life gives you the most joy and pleasure?
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If you could change one thing, what would it be?
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