Name

Address

City

State

Zip

Home Phone

Work Phone

Email Address

Status

New or Existing Student (circle one)

Health Information

Any condition that you feel might interfere with your Yoga, please talk to your instructor.
Please check any health conditions that apply to your (past or present):

*Heart Disease

*High Blood Pressure

Low Blood Pressure

Migraines

Stress Headaches

Sinus

Low Back Pain

Neck/Shoulder

Cancer

Stroke

Menstrual Discomforts

Carpal Tunnel

Arthritis

Fibromyalgia/Chronic Fatigue

Glaucoma

Seizures

Pregnancy (Week #)

Broken Bones (list)

Recent Surgeries (2 years)

* Must have permission from your Physician to participate.