Movement Readiness Questionnaire

By submitting and signing this form I acknowledge that I have voluntarily enrolled in a program of yoga instruction offered by Amy Soucy / Resonant Heart Yoga. I understand that yoga includes physical movements and conditioning, as well as an opportunity for relaxation, stress re-education and relief of muscular tension. Injuries of all types can occur and I assume full responsibility for any and all damages, which may incur through participation. Amy Soucy / Resonant Heart Yoga disclaims any liability for incidental or consequential damages and assumes no liability or responsibility for any loss, injury, or damage suffered by any person as a result of the use or misuse of any information or instruction through the business.

Name

First Name

Last Name

Phone

(###)

###

####

Name of program you're participating in (i.e. Embodied & Unshakeable, Zoom To Zen, etc.)

Have you've been advised by a medical professional not to participate in physical activity? (I.e. exercise, yoga, pilates, etc.)

Do you have any injuries, joint, or bone pain?

Have you been diagnosed with any chronic conditions such as heart condition, high blood pressure, diabetes, etc?

I understand that I should receive doctor's clearance before starting a movement program with physical activity

Do you take any medications that I should know about?

Movement Readiness Questionnaire

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