Yoga Student Information Form Page 2
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2Please indicate any areas you are currently experiencing pain or discomfort on the diagram below:
R side
L
R
R
L
L Side
Please list medications, remedies, and supplements: ____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Are you currently under the care of a doctor or other therapist? ___________________________
This form does not claim to treat any of the conditions listed above. Yoga instructors are in no way
intended as a substitute for medical counsel
.
Date: ________________________
Instructor: _____________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
R side
L
R
R
L
L side
Date: ________________________
Instructor: _____________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
R side
L
R
R
L
L side
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