Assessment Form : NHK YOGA

Customer Name

Age

Contact Number

Gender

Male Female

What is the purpose of doing Yoga?

Solve Medical Issues/Injury General Fitness Stress Management Flexibility Weight Loss Others (Please specify)

Do you now or have you had in the past?

Thyroid High/Low BP Surgery/injury Diabetes PCOD/PCOS Stomach/Digestive problems Back Pain Others (Please Specify)

Daily Activity Level?

Select Your Daily Water Intake (in liters):

Select How Many Hours of Sleep You Get Each Night:

Have you been in any other Yoga/Fitness program before?

Yes No