Flex Yoga and Massage - mobile yoga and massage in Adelaide
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New Client form
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Name
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First
Last
Phone Number
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Address
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City
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Email
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Would you like to join our mailing list?
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Already signed up
Information will not be supplied to third parties. The purpose will be purely for notification of upcoming events or last minute cancellations. You can opt out at any time.
Date of birth
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Emergency contact (name and number)
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Any previous medical history that may affect your yoga practice?
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High or low blood pressure
Pregnancy/given birth within last 3 months
Spinal problems including neck
Osteoporosis
Diabetes
Asthma
Heart condition
Joint replacement
Allergies
Dizziness
No known issues
Epilepsy
Other
Eye problems
Medical clearance may be required before participating in an exercise program
Mentally and emotionally, please describe how you feel on a daily basis.
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(i.e. stressed, disorganized, stuck, angry.. etc)
If you have selected any of the above, or have had injuries or surgery in the past 3 months, please specify
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Where in your body do you hold the most tension?
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Physically, please describe how do you feel on a daily basis?
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Please check all the words below that you would regularly use to describe yourself
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Anxious
Laid back
Stressed
High-strung
Energetic
Lethargic
Depressed
Calm
Organized
Disorganized
What does a typical week look like for you?
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Please describe any exercise routine, workload, recreation etc.
I regularly sleep well and wake feeling rested
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
What level practioner would you consider yourself to be?
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Complete beginner
Beginner
Irregular attendance, but have past experience
Regular attendance for more than 6-12 months
Experienced
Other
I handle stressful situations well (such as a car accident, illness or job loss)
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have multiple hobbies or self-care routines to wind down and manage my stress level
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have adequate relationship support from family, friends... etc
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
If necessary, I am willing to work hard to modify my habits, lifestyle and mind.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
What type of exercise do you currently participate in, and how often?
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Have you ever participated in a yoga class before?
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Yes
No
If so, do you know what style?
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Hot yoga (including bikram)
Hatha
Iyengar
Ashtanga
Yin/Restorative
Vinyasa flow/Power yoga
Huh?? I didn't know there were different types!
Which of the following would you like to achieve from your sessions?
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Strength training
Increased energy
Injury rehabilitation
Flexibility
Balance
Stress relief
Pain relief
Weight management
Relaxation
Meditation
Create a personalized yoga routine
What are the 3 main goals you would like to achieve from our time together?
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What type of yoga classes are you most interested in?
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Yoga for strength
Yoga for flexibility
Massage (therapy ball work)
Yin yoga (long, slow holds)
Relaxation, restorative yoga
Meditation
Yoga as a fitness tool (ie. I can handle a bit of sweat)
More than one can be selected
What class times suit you best?
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Weekend mornings
Weekend afternoons
Weekday mornings (before 9am)
Weekday mornings (after 9am)
Evenings (after 6:30pm)
Late evenings (after 7:30pm)
Are there any particular days/times that suit you best? Please be as specific as you can with your preferences.
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How did you hear about me?
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Internet Search
Advertisement
Friend
Social media
Other
If Other please specify:
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Informed Consent
I agree that I am in proper physical condition to participate in yoga classes, workshops and other wellness, exercise and healing arts activities (collectively, "the Activities") offered by Flex Yoga and Massage and its instructors including independent contractors. I agree that I am over 18 years of age (or legal guardian will be required to sign paper based consent form before participating).
I have been informed and understand that strength, flexibility and cardiovascular exercise, including Yoga, are potentially hazardous activities. I also have been informed and understand that these activities involve a risk of injury and that I am voluntarily participating in these activities with full knowledge and appreciation of the dangers involved. I understand that I could experience muscle, back and other injuries during exercise. I understand my physical limitations and am sufficiently self aware to stop physical activity before I become ill or injured. I understand it is my continuing responsibility to disclose Flex Yoga and Massage of any previous medical conditions, injuries or surgeries prior to my first class and any changes to my medical condition.
I understand that Flex Yoga and Massage will not be held responsible for any neglect on my behalf to seek medical approval prior to commencing the Activities. I also understand that classes taught at Flex yoga and Massage are not meant to replace any form of medication or medical treatment that I am currently seeking now or in the future.
I understand that if I am unable to keep my scheduled private lesson appointment, I must offer the courtesy of 24 hours advanced notice via phone call or text. Same day cancellations will result in full payment.
I understand that Flex Yoga and Massage may photograph or video classes or events and publish these materials on its Website or Social Media page. I hereby consent to the use of my image that may appear in such photograph or video unless otherwise informed.
I declare all of the information provided by me to be correct to my knowledge and have not withheld any information that may result in any consequences.
I agree to advise Deanne Kong from Flex Yoga and Massage in writing if any of the information provided by me changes.
I have read and understood the above Waiver of Release and Assumption of Liability
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Yes, I agree to the above
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