Yogira - Premium Client Intake Form

Basic Information Step 1 of 8

Full Name *

Age *

Gender *

Phone Number *

Email Address *

Occupation

Emergency Contact *

Lifestyle & Daily Routine Step 2 of 8

Working Hours Per Day

Sitting Hours Per Day

Average Sleep Duration (Hours)

Water Intake Per Day

Self-Assessment Daily Stress Level (1–10) 5

Relaxed & Calm Moderate Stress Extreme Burnout

Physical Activity Level

Previous Yoga Experience

Current Exercise / Gym Routine

Posture & Functional Assessment Step 4 of 8

Can you touch your toes without bending your knees?

Do you experience difficulty sitting cross-legged?

Do you experience difficulty balancing on one leg for 15+ seconds?

Areas of noticeable muscle tightness

Hamstrings Lower Back Shoulders Hips Neck

Functional Capacity (Rate difficulty of basic actions)

Activity	Easy	Moderate	Difficult
Climbing stairs
Sitting on the floor
Standing for a long time
Forward bending

Breathing Profile

Do you experience shortness of breath?

Where do you naturally direct your breath?

Do you experience breathing difficulties (hyperventilating/tightness) when stressed?

Mental & Emotional Wellness Step 5 of 8

What is the primary source of stress in your life?

Average energy level throughout the day

Do you practice meditation or breathwork currently?

What are your primary mental/emotional goals? (Select all that apply)

Calmness & Peace Confidence Better Focus Emotional Balance

Commitment & Preferences Step 7 of 8

Preferred Class Timing

Online or Offline?

Preferred Intensity Level

How many days per week can you practice?

Days Available (Select all that apply)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Consent, Disclaimer & Uploads Step 8 of 8

Posture Analysis Photos (Optional)

Providing posture images from front, side, and back profiles allows the coach to spot skeletal alignment issues.

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Front Profile

JPG, PNG (Max 5MB)

File Selected

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Side Profile

JPG, PNG (Max 5MB)

File Selected

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Back Profile

JPG, PNG (Max 5MB)

File Selected

Medical Reports & MRI (Optional)

If you have diagnosed spine, knee, or doctor notes regarding exercise limitations, upload them here.

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Upload Reports / Prescription

PDF, Docx, or Images (Max 5MB)

File Selected

Consent & Disclaimer: I confirm that the information provided is accurate to the best of my knowledge. I understand yoga is not a substitute for medical treatment or clinical diagnostics and I will inform the instructor immediately about any discomfort, pain, or dizziness during practice. *

Yoga Client Assessment

Basic Information Step 1 of 8

Lifestyle & Daily Routine Step 2 of 8

Health & Medical History Step 3 of 8

Pain & Discomfort Assessment

Posture & Functional Assessment Step 4 of 8

Breathing Profile

Mental & Emotional Wellness Step 5 of 8

Goals Section Step 6 of 8

Commitment & Preferences Step 7 of 8

Consent, Disclaimer & Uploads Step 8 of 8

Menstrual Cycle Information (Female Clients)

Posture Analysis Photos (Optional)

Medical Reports & MRI (Optional)