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Yoga Central — Student Intake Form

All information will be treated in the strictest confidence.

📋 Your Details

Full Name *

Date of Birth

Email Address *

May we add you to the Yoga Central mailing list?
Stay informed about local retreats and useful yoga articles.

Yes No

Have you attended yoga classes before? *

Yes No

Are you currently undergoing any medical treatment or have you recently had surgery? *

Yes No

Please provide details:

Please give information on any injuries or fractures you may have had in the past 3 years:

Do you suffer from back pain or other back problems? *

Yes No

Please describe:

Do you have a history of pulled tendons, ligaments or muscles? *

Yes No

Please describe:

Are you pregnant, or have you recently given birth? *

Yes No

Please provide details (stage of pregnancy or how recently you gave birth):

Are you currently breastfeeding? *

Yes No

Do you currently smoke? Do you suffer from respiratory issues? *

Yes No

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