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KOURTNEY FEINSTEIN YOGA CLIENT INTAKE FORM

Disclaimer: Thank you for your interest in being a student of Kourtney Feinstein. This form is used to collect information about new students and for internal purposes only. The information you provide is confidential and will be treated accordingly.

STUDENT GENERAL INFORMATION

Birthday
Month
Day
Year

YOGA EXPERIENCE/GOALS

Have you practiced yoga before?
Yes
No
If yes, when was your last class/practice?
How often do you practice yoga?
What style of yoga have you practiced most frequently? (check all that apply)
What are your goals/expectations in yoga? What benefits do you seek? (check all that apply)
What are your personal yoga interests?

LIFESTYLE AND PHYSICAL HISTORY

How do you rate your current level of physical activity?
Check the conditions that have affected your health either recently or in the past.
Are you currently taking any medications?
Yes
No
If yes, please list the names and reasons for the medications

ACKNOWLEDGMENT

By attending this class, I affirm that I am solely responsible for my health and well-being, as well as my decision to practice yoga, a program of physical exercise. I agree to inform my yoga instructor of any activities or movements which I feel could cause injury to myself. I understand that

yoga/meditation/breathing techniques are not recommended and are not safe under certain medical conditions. I do not have any physical conditions or disability that would limit my participation or preclude an exercise program. Kourtney Feinstein shall not be held liable for any injury, loss, or damage to property and/or persons sustained during or as a result of participation in these classes. I agree to listen to my body and monitor myself during every class session.

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