Private Yoga Session Shannon Crow Yoga 2015

Name: / Telephone: ( )
Mailing Address: Street / City/Town Postal Code
Email: / Birthdate: MM/DD/YYYY
May we contact you by email? / Yes No
How did you hear about Shannon Crow Yoga?
What are your primary goals for this class?
Please circle the activities you have done. / Yoga Meditation Dance Sports
What other forms of exercise do you do?

Private Yoga Session Shannon Crow Yoga 2015

Private Yoga Session Shannon Crow Yoga 2015

Please check any existing or past conditions:

High blood pressure
Back/neck pain
Knee pain
Low blood pressure
Hip pain
Anxiety/depression
Glaucoma
Pregnancy (current)
Low blood sugar

Please list any other health concerns, injuries, allergies or medical conditions.

Private Yoga Session Shannon Crow Yoga 2015

In any physical activity, risk of serious physical injury is possible. Yoga and other activity is no substitute for medical diagnosis and/or treatment. The student assumes the risk of yoga or other activity and releases the teacher(s) and Shannon Crow from any liability claims.

I, ______(please print name), am participating in classes or workshops with Shannon Crow. I am aware of the physical risks involved with exercise and understand it is my personal responsibility to consult with my doctor regarding my participation. I have no medical condition, which I am aware of, that would prevent me from taking part in classes or workshops, and I assume responsibility for any risk or injury I may sustain as a result of my participation. I have read the above release and waiver of liability and understand its contents. I understand that it is my responsibility to find a pace that suits me. I agree to the terms and conditions stated above.

Date MM/DD/YYYY

Signature______

MC S

Date of session: Location: Time:

Check-In:

Energy on a scale of 1-10 1 2 3 4 5 6 7 8 9 10

Physical Body:

Emotional:

What has worked (previous sessions and/or other activities that improve health):

Goal of this session: build strength relaxation meditation flexibility increase focus decrease pain therapeutic breath practices learn about yoga yoga philosophy build an at-home practice

Pose ideas for this session:

Actual poses used in session:

Homework:

Notes:

Student Feedback:

On a scale of 1 to 10 please rate your experience of the private yoga session today. All feedback is helpful to help Shannon improve as a teacher and to create a class tailored to your specific needs.

1 = not at all 5 = kind of 10 = yes very

I felt heard and understood today.

1 2 3 4 5 6 7 8 9 10

The instructions were clear and concise.

1 2 3 4 5 6 7 8 9 10

I felt comfortable asking questions and felt that they were answered.

1 2 3 4 5 6 7 8 9 10

I feel better now than when we began today’s session.

1 2 3 4 5 6 7 8 9 10

What were your favourite elements/poses of today’s private class?

What would you like left out of future sessions in terms of elements or poses?

Feel free to offer any other feedback below or on the back of this page.