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Winter 2020
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Health Questionnaire for Private Yoga
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
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Yoga class date / time
*
Date format ex: 2/1/18 10 - 11am
1. Do you have a history of the following conditions?
*
Diabetes
Irregular heartbeat
Seizures
Asthma
Fibromyalgia
Thyroid Disorder
None of the Above
Other
If Other please specify:
*
2. Do you currently experience or have a history of the following injuries or orthopedic concerns?
*
Joint Issues
Arthritis
Disc Issues
Bursitis
Low Back Pain
Knee Pain
Sciaticia
Foot Cramps / Pain
Tendonitis
Ankle Sprains
Nerve Pain
Rotator Cuff Injury
Shoulder / neck pain
Hip pain
None of the Above
3. Do you have any other medical condition(s) or issues with a particular aspect to your health/body not previously mentioned?
*
Yes
No
If Yes, please explain.
*
4. Are you currently taking any medications?
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Yes
No
If Yes, please explain.
*
5. Current fitness activities and frequency – please describe:
*
6. What is your main request for private Yoga session (s)?
*
Emergency Contact
*
First
Last
Please acknowledge
*
Yes, I have answered the above questions to the best of my knowledge and have not withheld any relevant information.
Emergency Contact Phone
*
Submit
Please contact us below to get a quote for Private Sessions with Teddi McEwen
Contact us for a quote
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
I am interested in information about Private Yoga session(s)
*
Submit
Home
Winter 2020
Accommodations
Survey
CONTACT
About Us
Michele's Classes
Teddi's Classes
Upcoming retreats
Past Retreats
Winter 2019 Photos
Fall 2018 Photos
Spring 2018 Photos
Fall 2017 Photos
Spring 2017 Photos
Winter 2017 Photos
TESTIMONIALS
Exhale808