Private Questionnaire

Please complete before meeting

Private/semi-private lessons take place Ricky's private studio in Carrollton, TX or via Skype or FaceTime.
Cash/Check or Venmo app preferred (@popupyoga-dallas)
Payment is required at the time of booking.
Cancellations must be made via email via [email protected].
For cancellations made less than 24 hours in advance, the full fee is due.
Exceptions are only made for clients who encounter unforeseen, life-threatening medical emergencies and family deaths/funerals.
Packages must be used within 2 calendar months.
Packages are non-transferable and non-refundable.
Must address all questions below.

THE DETAILS IN THIS FORM ARE KEPT BY KRAMA YOGA CENTER FOR THE PURPOSE OF DESIGNING YOUR YOGA PRIVATE SESSIONS ONLY. YOUR INFORMATION IS KEPT COMPLETELY CONFIDENTIAL AND IS NEVER SHARED.

Personal Info

I have read and agree to the policies above. * *

YES

* Indicates required field

Students Name *

First

Last

Referred by *

First

Last

Do you prefer any particular teacher for the private lesson(s)? *

Email *

Re-enter Email *

Phone Number *

Re-enter Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Age *

Weight (lbs.) *

Height (feet and inches) *

Emergency Contact *

First

Last

Emergency Contact Phone *

Emergency Contact Relationship *

Diet

How many times per day do you eat? *

What are the sizes of your meals? *

Please describe your weekly diet in terms of meat, seafood, dairy, fruits, vegetables, grains, water, tea, coffee, energy drinks, sodas, etc. *

Rate your digestion: *

Rate your breathing: *

Are you a nose or mouth breather? *

Nose Mouth Unsure

If mouth breather, why? *

Asthma? *

Blood Pressure: *

If blood pressure abnormal, is it controlled with medication and type? *

History of heart disease? Please elaborate: *

History of drug abuse? Please elaborate: *

History of anxiety or depression medication and how long? *

Current perceived stress level: *

Low Moderate High

How well do you sleep? *

Badly Moderate Well

On average, how many hours of sleep do you get each night and the quality of rest you receive from it? *

Standing: *

Rarely Sometimes Often Most of the day

Carry heavy weight: *

Rarely Sometimes Often

Travel by plane *

Rarely Sometimes Often

Please list all current medication and reason: *

Please list current exercises and physical activities: *

Please list previous yoga experience: *

Please list team or competitive sports: *

Please list prior and/or current injuries or health conditions and explain: *

Please list your goals for practice/lessons: *

When are the best times for you to meet up? *

Release/Wavier of Liability and Agreement

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, adjust the posture and ask for support from the teacher. I will continue to breathe smoothly. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I have been checked by my doctor and cleared to practice yoga prior to signing up for private lessons with Krama Yoga Center. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Krama Yoga Center, their heirs, successors or assigns. I agree to the above policies and pricing for private yoga lessons with Ricky Tran Yoga *

YES

I agree to receiving marketing and promotional materials

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