Krishnamacharya Healing & Yoga Foundation
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Teacher
Referred by
Name
Gender
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Female
Male
Marial Status
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Single
Married
Separated
Living with partner
Widowed
Occupation
Childeren Names & Ages
Address 1
Address 2
Phone Number
Email Address
Hight and Weight
Energy Levels
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Excellent
Good
Moderate
Poor
Erratic
Appetite
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Excellent
Good
Moderate
Poor
Erratic
Sleep Onset
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Easy Onset
Late Onset
Inconsistent
Quality of Sleep
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Excellent
Good
Moderate
Poor
Erratic
Bowel Movement
Please Select
Regular
Irritable
Constipated
Erratic
Exercise Habits
Type of Delivery
Please Select
Normal
Caesarian
Not Applicable
Menstrual Cycle
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Option 1
Option 2
Option 3
Activities & Interest
Family History Mother
Please Select
Asthma
Obesity
Arthritis
Diabetes
Cardiac Problems
Other please specify
Other Please Specify
Family History Father
Please Select
Asthma
Obesity
Arthritis
Diabetes
Cardiac Problems
Other please specify
Other Please Specify
Medical History: Please list any prior surgeries or major illnesses
Current Medication: Please list any prior medication that you are currently taking
Previous Yoag Experience: Please list briefly any prior yoga experience that you have had
What benefits do you hope to get from yoga practice? Please list what you hope to get from the yoga therapy process that you are about to begin
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