Intake Form Name * First Name Last Name Date of birth * MM DD YYYY Email * Number * Emergency contact name (First and last) * Emergency contact phone number (Incl. country code) * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Health and fitness questions How would you describe your current level of personal health? * Very healthy Average health (Perhaps with a chronic condition) Constant health issues Very poor health How would you describe your current fitness levels? * Excellent, extremely fit Good fitness levels, considered above average Below average fitness Very poor fitness, completely unfit If you have any diagnosed health problems and/or injuries please list the condition(s) and any therapies that are being undertaken. * Lifestyle questions Do you follow a regular working schedule, do you work days, afternoons or nights? * Please list any physical activities that you participate in. * Are you experiencing any stress or motivational problems? Please elaborate. * How have you been sleeping lately? * Your experience with Yoga, Reiki, Meditation Have you done Yoga, Meditation and/or Reiki before? If yes, what styles of Yoga, Meditation, type of Reiki, and how often? * What is your primary reason or goal for wanting sessions with me now? * What would you most like to get out of your sessions? List as many goals as you wish! * Disclaimer: I understand that Yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the 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 signature verifies that I have my physician's approval to participate. 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 ‘Holistic Wellness by Evi’ and its instructors. * I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as a complete and unconditional release of all liability to the greatest extent allowed by law in the United Kingdom. Terms of Service: Please copy and paste the following link in your browser to read the ToS >>> www.holisticwellnessbyevi.com/terms-of-service * I have read and fully understand and agree to the Terms of Service. Thank you for taking the time to provide this information. See you soon for our first session. “Yoga, Reiki, Meditation, Ceremonial Cacao and other Rituals are helping me transform my life, and I will help you transform yours too.” Let’s Begin Book a free discovery Call
