Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Occupation
*
Enneagram Number
*
1
2
3
4
5
6
7
8
9
Unknown
Height
*
Weight
*
What main concerns would you like to address in our time together?
*
Present Health Status
*
Past History of Health
*
List any surgeries, injuries, or medical issues you've experienced with approximate dates. Please be thorough.
Are you under the care of a physician?
*
Yes
No
If yes, for what reason?
Are you cleared for exercise?
*
Yes
No
Any known physical restrictions?
*
If yes, please list.
Current Treatments/Medications/Vitamins/Supplements:
*
Please list any medications, vitamins, or supplements you take and why.
What types of therapies or practices have you tried for these problems or to improve your physical, mental, and emotional health overall:
*
Regular Activities / Exercise:
*
Goals you wish to achieve through yoga and enneagram coaching:
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Please describe your previous experience with Yoga, if any:
*
Liability Release
*
The information that you receive during your private session is not intended as a substitute for the advice of physicians or other qualified health professionals. It is not intended to be prescriptive with reference to any specific ailment or condition or to the general health of the client, but rather, descriptive of one approach to fostering health and wellness. The client is advised to consult with his or her physician in matters relating to his or her health, particularly in respect to any symptoms that may require diagnosis or medical treatment.
Waiver of Liability and Assumption of Risk
The undersigned client (or parent or legal guardian of the client, if the client is under 18 years of age) acknowledges that the practice of yoga and the use of facilities and services involves an inherent risk, and hereby assumes all risks incident to such activity. By registering to practice yoga with Abi Robins, the client (or parent or guardian) represents that they are in adequate physical condition to practice yoga, based on own assessment and are not relying on any representations made by Abi Robins. Client waives any claim or right of action against Abi Robins for loss, expenses, liabilities, damages or legal fees incurred on account of any loss or injury to the client or client’s property incurred in connection with and/or as a result of the client’s attendance at classes conducted by Abi Robins and/or the use of facilities or services.
Cancellation Policy
*
