STUDENT INTAKE FORM | Suzanne Drolet Yoga

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Suzanne Drolet Yoga Therapy

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Client Intake Form

First Name

Last Name

Email

Phone

What are your primary reasons for seeking private yoga/yoga therapy?

How would you describe your overall health?

Please indicate any conditions you are currently experiencing:

Neck/Back/Joint Pain or Issue

Physical Trauma

Arthritis

Respiratory Condition

Stress

Cardiovascular Condition

Parkinson's Disease

Headaches/Migraines

Insomnia

Depression/Anxiety

Diarrhea/Constipation/IBS

Diabetes/Metabolic Syndrome

Cancer

Gynecological/Urological/Pregnancy

Other (Please describe, below)

Please list any medications and/or treatments you are taking for your health condition(s).

Please use this space to inform me of any questions you may have relative to your full participation in yoga therapy.

Thank you - I will be in touch with you soon.

CLIENT RESOURCES

COVID-19 Policies In-Person Yoga

Cancellation Policy

Release of Claims

LET'S CONNECT

Oakland, CA

life_love_yoga@comcast.net

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© 2021 Suzanne Drolet Yoga and Yoga Therapy

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