Private Questionnaire

SCHEDULE WITH ME

Testimonials

Private Lessons Questionnaire

Personal info

* Indicates required field

Name *

First

Last

Referred by: *

Email *

Re-enter Email *

Phone Number *

Re-enter Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Upload Photo so I will know who I'm working with! *

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Occupation *

Age (years) *

Weight (lbs) *

Height (feet, inches) *

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relationship *

Diet & Lifestyle

How many times do you eat per day? *

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: *

Are you a nose or mouth breather? *

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 anxiety or depression medication and how long? *

Current perceived stress level: *

Quality of sleep? *

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

Sitting at a desk or driving: *

Standing *

Carry heavy weight: *

Travel by plane: *

Please list all current medication and reason: *

Please list current exercises and physical activities: *

Please list team or competitive sports: *

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

MOST IMPORTANT Please list your goals for practice/lessons: *

When are the best days and times for you to meet? *

Any additional comments or concerns? *

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 Ricky Tran. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Ricky Tran, their heirs, successors or assigns. I agree to the above policies and pricing for private yoga lessons with Ricky Tran

I have read above and agree. *

I agree.

Policies

A payment is required to get on my schedule for our first session. We can discuss options. Thank you.
Most my clients meet 1-2 times per week and make monthly, quarterly, semi-annual or annual commitments.
Standard practice is to confirm the following month's schedule and prepay for the booked times.
Cancellations are to be made via email or text for time stamp documentation. For cancellations made less than 24 hours in advance, the full fee is due.
Exceptions are made for clients who encounter unforeseen, life-threatening medical emergencies and family deaths/funerals.
Roll-over sessions are approved per incident and are credited to the following month's sessions.
Packages are non-transferable and non-refundable.
The details in this form are kept for the purpose of designing your yoga private session only.
Your information is kept completely confidential and is never shared.

I agree to the policies above. *

I agree

Submit. Thank you!

Private Client
Questionnaire

Private Lessons Questionnaire

Personal info

Diet & Lifestyle

RELEASE/WAVIER OF LIABILITY AND AGREEMENT

Policies

To whom I lend loving credit.

Private Client​Questionnaire

Private Lessons Questionnaire

Personal info

Diet & Lifestyle

RELEASE/WAVIER OF LIABILITY AND AGREEMENT​​

Policies

To whom I lend loving credit.

Private Client
Questionnaire

RELEASE/WAVIER OF LIABILITY AND AGREEMENT