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Yogaville Program Guide Summer/Fall 2016
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Yoga Therapy and Healing Lifestyle Information Form
Please take a moment to help me get to know you better by filling out the below form. – Bob Butera
Emergency Contact Name
Emergency Contact Phone
Tell me a little about your lifestyle? Diet? Exercise program? Do you smoke or drink?
Do you use Nutritional Supplements and/or do you take any prescription medications? If yes, please list those. Are there any side effects that you experience?
Do you awaken from sleep feeling rested? Do you fall asleep easily?
How is your stress level?
What types of situations trigger stress or bring it on for you?
What are some of the ways you find most effective for releasing stress?
How do you have fun in your life? How well do you feel you nourish yourself with food, love and laughter?
How would you describe your state of mind most of the time?
What is your experience with Yoga and meditation?
How often do you practice and is your practice regular?
What have you found most beneficial from these practices?
What have you found most difficult or challenging?
What do you hope to get out of Yoga practice? What is your main goal for Yoga practice?
Please mention any other health or medical condition that you believe may be helpful to your instructor and any precautions that should be taken to help ensure your well-being.