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TAMM 2.0
Helping families of ethnic descent find a sense of identity, worthiness & belonging
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Health Form
ABOUT YOU
Name
*
First Name
Last Name
Email
*
Birthday
MM
DD
YYYY
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
(###)
###
####
Help me serve you better
Have you done yoga before?
(If the answer is no please skip to question 4)
Yes
No
If so what style(s)?
How many years have you been doing yoga, and on average , How often?
What other forms of exercise do you do?
How long have you been doing these other forms of exercise, and how often?
On a scale of 1 – 10, how stressful is your job?
What are your expectations and/or goals from your yoga class?
Do you suffer from any of the following health issues? Check where applicable.
Arthritis
Blood Pressure
Eye Issues
Migraines
Asthma
Diabetes
Epilepsy
Back Pain
Ear Issues
Heart Condition(s)
Anxiety
Stress
Hypertension
Thyroid
Digestive Issues
Other
Are you pregnant?
Yes
No
Have you under gone any recent surgeries?
Is it ok if the teacher makes hands on adjustments for alignment, poses, also during therapeutic relaxation to aid opening of joints?
Yes
No
Are you ok with use of the following?
Essential oils
Sprays
Incenses
Camphor
Burning sage and sweet grass
Please add any further comments, questions, and/or concerns here.
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation.Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in such a fitness program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Wellness By Roma LLC and it's instructors.
I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my Print name below represents my signature and serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of New Jersey.
Signature
*
Date
MM
DD
YYYY
ALL INFORMATION IS STRICTLY CONFIDENTIAL
THANK YOU FOR FILLING THIS FORM
