Intake Form Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Emergency Contact Name First Last Emergency Contact PhoneHave you practiced yoga before? Yes No How often do you practice yoga? Never Once every few weeks Once a week A few times a week Daily What styles of yoga have you practiced before? Ashtanga Hot Yoga Bikram Yoga Kundalini Yin/Restorative Yoga Power Yoga Hatha Yoga Iyengar Vinyasa Yoga Not sure On a scale of 1-10 (10 being the highest), how would you rate your level of daily activity?Please enter a number from 1 to 10.On a scale of 1-10 (10 being the highest), how would you rate your level of daily stress?Please enter a number from 1 to 10.What are your health goals for your yoga practice? General wellbeing Weight loss/maintenance Strength building Stress relief Flexibility Improve overall health Alternative therapy (explain below) Address specific health concern (explain below) Balance/Inner Peace Other Which aspects of yoga are you most interested in? Physical postures Breath-work/Pranayama Meditation Please review the following list and check any health conditions that apply to you or have applied to you recently. Arthritis Osteoporosis Muscle pain Muscle Weakness Scoliosis Bulging Disc Degenerative Disc Back pain/injury Anemia Sciatic Diabetes Asthma, shortness of breath Seizures Stroke Heart conditions, chest pain Anxiety Depression High Blood Pressure Low Blood Pressure Surgery (explain below) Knee Pain/Injury Cancer (explain below) Pregnancy (explain below and estimated due date) Other/Explain Are you currently taking any medications? Yes No If so, please list the names and reasons for medications. Consent(Required) I authorize the collection and use of the above personal information as is required for therapeutic treatment and related administrative purpose. I understand that all my personal information is confidential and will not be released without my signed consent. I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions.Consent(Required) I affirm that a licensed physician has verified my good health and physical condition to participate in yoga classes offered by Ananda Yoga/Angela Goldrup. In addition, I will make my yoga instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my approval and consent verifies that I have my physician's approval to participate.Consent(Required) I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Ananda Yoga/Angela Goldrup and/ or any other persons who may teach at Ananda Yoga/Angela Goldrup.CAPTCHA
