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Course Intake Form
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Name
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First
Last
Phone Number
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Email
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Occupation
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What is your age?
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Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
Which best describes your experience with yoga?
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I’ve never practised yoga before
I’ve been to a few classes
I’ve been to a bunch of classes
Which best describes your current level of fitness?
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Challenged
Average
Good
Excellent
Which best describes your current level of flexibility?
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Challenged
Average
Good
Excellent
Please describe any regular exercise you undertake (e.g. walking, running, gym, Pilates)
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What are your main reasons for coming to yoga?
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Physical fitness
Stretching and flexibility
Increase vitality and energy
Support for a specific injury or physical ailment
Stress management
Mental / emotional health
Specific health condition
Please tell us a little bit about why you’re attending the beginner course and what you hope to get out of it?
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Please indicate if any of the following apply to you:
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Asthma or breathlessness
Low blood pressure
Spine or neck ailments
Muscle / joint / tendon problems
Recent surgery
Illness or chronic conditions
Anxiety / depression / stress / mental health
Pregnant / post natal
Other
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