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Yoga Intake Form

Yoga & Meditation Intake Form

Information About You
Name*
First Last
Email*
Phone*
Emergency Contact Name and Phone Number*
How much experience do you have with yoga and meditation? (e.g. none, a few classes, videos/DVD’s only, X months, X years, etc.)
What other physical exercise/activities do you currently engage in? How many times per week?
Do you have any current injuries or physical limitations?
Please indicate which of the following conditions you have and provide any pertinent details, including any medication you are taking in "Notes":
- Osteoarthritis
- Rhematoid Arthritis
- Back Pain
- Osteoporosis
- Knee Replacement
- Hip Replacement
- High Blood Pressure
- Cardiovascular Disease
- Pulmonary Disease
- Glaucoma or Detached Retina
- Hearing Loss
- Insomnia
- Anxiety
- Depression
- PTSD
- Other (specify in notes)
Notes:
Do you have any questions or concerns?
I hereby certify that the above information is true and complete to the best of my knowledge. I agree that it is my responsibility to ascertain that there is no medical reason to prevent my participation. I will take full responsibility for not exceeding my limits and for any injury I might suffer in these practices. I hereby waive any claim injury of any sort against Hospice Savannah, the Edel Caregiver Institute, its teachers or any person or entity in any way involved herewith. I have carefully read this release and fully understand and agree to the above. Please type name and date in box to acknowledge agreement and denote as signature.*
Email
This field is for validation purposes and should be left unchanged.

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Hospice Savannah, Inc.
1352 Eisenhower Drive
Savannah, GA 31406
912.355.2289

Mailing address:
P.O. Box 13190,
Savannah, GA, 31416

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Yoga Intake Form

Yoga & Meditation Intake Form

Information About You