Questionnaire

SCHEDULE WITH ME

Testimonials

Returning Student

Please submit questionnaire for complimentary 15 min phone interview

Private/semi-private lessons take place at Ricky's home studio in North Dallas 75287 near Midway and Briargrove. Home or office visits are negotiable. Out of town visits are also available.
With 15+ years and 24,000+ hours of experience and tremendous client results, the private rate is $300 per hour effective new clients beginning Jan 2021.
If you schedule weekly lessons and pay monthly, I'll give extra time, per session, as needed, up to 30 minutes as needed at no extra charge.
Venmo @RickyTranYoga, Zelle ricky@rickytranyoga.com or Cash/Check payable to Krama Yoga Center.
Cancellations must be made via email via ricky@rickytranyoga.com.
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 1 calendar month. Roll-over sessions are approved per incident.
Packages are non-transferable and non-refundable.
Must address all questions below. N/A if not applicable.
The details in this form are kept by Ricky Tran for the purpose of designing your yoga private session only. Your information is kept completely confidential and is never shared.

Questionnaire

I have read and agree to the policies above. *

Yes

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

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? *

[HEALTH DECLARATION]

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 agree. (Please make sure the form is properly submitted. If required fields are not filled out, the form will not send.)

Submit

Private Student
Questionnaire

Please submit questionnaire for complimentary 15 min phone interview

Questionnaire

Personal info

Diet & Lifestyle

[HEALTH DECLARATION]

RELEASE/WAVIER OF LIABILITY AND AGREEMENT

I give these beloved teachers credit.

Private Student​Questionnaire

Please submit questionnaire for complimentary 15 min phone interview

Questionnaire

Personal info

Diet & Lifestyle

[HEALTH DECLARATION]

RELEASE/WAVIER OF LIABILITY AND AGREEMENT​​

I give these beloved teachers credit.

Private Student
Questionnaire

RELEASE/WAVIER OF LIABILITY AND AGREEMENT