Yoga Shala Therapeutic/Special Needs Intake Form Name First Last Email PhoneMessage to Yoga Shala DirectorsPregnancy (# of weeks)Joint pain, restrictions, or replacements (give details)Accidents, injuries, surgeries (with dates)Pain - Episodic or chronic; nerve, muscular or joint painSystemic issues: (immune conditions, movement disorders, chronic fatigue, high blood pressure, etc.)Brain injuries, perceptual issues (hearing, sight), dizzinessAnxiety, depression, PTSD, etc.Other diagnoses (cancer, etc.)Are you able to easily get up and down off of the floor?In the last year, if you had an accident, surgery, or major medical issue, has you doctor cleared you to attend yoga classes and return to normal activities? Yes No Is there anything else that might affect you during a yoga class?