Joy and Grace Yoga Health Intake 
In order to keep you safe and best serve you during any group programming or private session with Joy and Grace Yoga, certain medical information is required prior to participation. Any person with a history of organ transplant or current pregnancy may not participate in yoga classes or sessions with Joy and Grace Yoga. 

By filling out this form you agree all information is correct and true. All participants are responsible for their own safety and to follow instructions as given during any programming or session with Joy and Grace Yoga. A separate liability waiver will be required prior to participation. 

 *Please note all information on this form is kept confidential by Joy and Grace Yoga and is protected under Google's HIPPA compliance agreement. 
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First and Last name *
email *
Today's Date *
MM
/
DD
/
YYYY
Please indicate if you have any of the following medical conditions *
Required
Please give more details about each thing you checked above unless you checked "none of the above"
Please list any prescription medication or supplements you are on and for what condition. If none, state "none." *
Have you had any significant  injuries or illnesses in the past 6  months?
If yes, please explain. If no, state "none"
*
Do you have any restrictions in your physical movement/ has your doctor ever told you there are certain movements you should not do? 
If yes, please explain. If none, state "none"
*
Have you ever had surgery? 
If yes, please explain. If no, state "none."
Have you ever had an organ transplant? *
Do you have any ongoing/chronic pain? If so please describe: where is the pain, for how long have you had it, is there a medical diagnosis associated with it, what helps and what makes it worse? *
How much sleep do you typically get, and is it enough for you? *
What other wholistic practitioners do you work with?  Please describe. *
How would you rate your overall physical health? *
very poor
excellent-no issues, no pain, nothing needs improvement
How would you rate your overall mental health *
very poor
excellent
How would you rate your overall spiritual health? *
very poor, not something i pay attention to
excellent- i have a strong spiritual base and practice
Are you currently pregnant? *
Emergency contact name and phone number *
I agree all of the above is true and accurate to the best of my knowledge and I have not excluded any medical information. *
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