Intake by xiaopangnv


									Today’s Date: ______________


Name:_____________________________________________ DOB:___/___/______


Home Phone:(____)______________                        Email:___________________________________

How did you hear about SolarVibe Yoga? __________________________________________________________

Have you had Yoga, Massage or other Wellness Services before? How was that experience?

Please describe any current concerns you may have and when they began:

Health History:
Broken Bones______ Injured Muscles_______ Prosthesis________ Pins/Bars______ X-Rays_______
MRI ______ CT scans______ Surgeries ______ Trauma/Accident_______ Hospitalizations________
Please Describe: ______________________________________________________________________
List Current Medications:_______________________________________________________________
Are you pregnant or trying to become pregnant? YES / NO
Do you have any Allergies? YES / NO ____________________________________________________

Please indicate conditions and whether those conditions are past/present:
      Arthritis_________________         H/L Blood Pressure________                  Poor Circulation ________
      Asthma______________               Headaches ______________                    Sciatica______________
      Blood Clots____________            Heart Conditions_________                   Sinus Problems___________
      Bruising_________________          Joint Pain_____________                     Seizures_______________
      Cancer__________________           Lymph nodes                                 Skin Disorders__________
      Depression_______________          removed________________                     Stroke_________________
      Disc Problems____________          Neck Pain_______________                    Varicose Veins__________
      Fatigue________________            Osteoporosis___________                     Other:__________________
      Fractures_______________           Pinched Nerves_________

      Confidentiality Agreement
        Client Records, health history, current health status and treatments maintained by this wellness facility
      are confidential and may not be disclosed without written consent. Your health history information may
      be discussed behind closed doors between practitioners and/or fitness instructors in this office for clinical
      reasons. Your signature below indicates your consent to this agreement.
        Shine Studio and Shine Massage Therapy offers a variety of complimentary healing modalities. I, the
      undersigned, understand that these sessions are not a substitute for medical or psychological diagnosis or
      treatment, nor should they interfere with the diagnosis and treatment of licensed medical practitioners. I
      understand that by signing below I consent to the release of my health history to the complimentary care
      practitioner for the purpose of my treatment only.

      Signature: _______________________________________________ Date:_____________________
                Agreement of Release and Waiver of Liability Form

I, ________________________________________________________ (Print Name)
hereby agree to the following:
       That I am participating in the Yoga Classes and/or Workshops, offered by Carolyn
LaSalle, aka SolarVibe Yoga; during which I will receive information and instruction about yoga
and health. I recognize that yoga will require physical exertion, which may be strenuous and may
cause physical injury, and I am fully aware of the risks and hazards involved.
       I understand that is it my responsibility to consult with a physician prior to and regarding
my participation in the Yoga Class or Workshop. I represent and warrant that I am physically fit
and I have no medical condition, which would prevent my full participation in the Yoga
       In consideration of being permitted to participate in the Yoga Class or Workshop, I agree
to assume full responsibility for any risks, injuries or damages, known or unknown, which I
might incur as a result of participating in the program.
In further consideration of being permitted to participate in the Yoga Class/Workshop, I
knowingly, voluntarily and expressly waive any claim I may have against Carolyn LaSalle for
any injury or damages that I may sustain as a result of participating in the program.
       I, my heirs or legal representatives, forever release, waive, discharge and covenant
negligence or other acts.
       I have read the above release and waiver of liability and fully understand its contents. I
voluntarily agree to the terms and conditions stated above.

REGISTRANT’S SIGNATURE: ________________________________ DATE: ___________

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