Brahmagyan Prachar Samaj

Satsang & Dhyan Shibir

www.brahmagyanlife.org
brahmagyansamaj@gmail.com
Registration Information Form

Name:
________________________________________________________________________________________________
Address:
______________________________________________________________________________________________
_______________________________________________________ Postal Code
_______________________________
Phone: Day ________________________ Eve.________________________ Email:
______________________________
Do you participate in any other physical activities?
____________________________________________________
Have you taken Meditation before? ________________________________________________________________
What are you looking for in your classes? :

_______________________________________________________________________

All information is strictly confidential.

Please check any medical/physical conditions shown below, if applicable, please.
High Blood Pressure ( ) Low Blood Pressure (
) Eye/Ear Problems (glaucoma, detached retina)
( )
Sciatica ( ) Wrist Problems (Carpal Tunnel) ( )
Arm/Shoulder Injuries ( ) Arthritis ( )
Hernia ( )
Knee Injuries (
) Neck Issues ( ) Back Problems ( ) Heart Problems ( ) Pregnancy (
)
Diabetes ( ) Fibromyalgia ( ) Dizziness ( ) Scoliosis ( ) Anxiety Disorders ( ) Depression
( )
Joint Replacement (
) MS ( ) Parkinsons (
) Osteoporosis ( ) Recent Surgery ( ) Other (
)
If checked, please
explain____________________________________________________________________________
Are you presently under the care of a physician?
_____________________________________________________
Is your physician aware of your participation in the classes?
__________________________________________

Have your practiced yoga before? YES

(If yes, date of last practice)

NO

How often do you practice yoga? (daily, weekly, monthly)?

Styles of yoga practiced (circle all that apply): Hatha, Ashtanga, Vinyasa/Flow,
Iyengar, Power, Kundalini, Gentle, Restorative, And Other

Style(s) most practiced or preferred:

Goals
What goals to you wish to accomplish through yoga therapy (circle all that apply)?
strength training
flexibility
balance

improve overall fitness

weight management
stress reduction

process loss/grief
aid healing female issues
increase personal well-being

Learn: proper alignment, postures (asana), breath work (pranayama), meditation

Lifestyle Habits and Wellness Behaviors
Fitness Behaviors:
How do you rate you current level of activity (circle one)?
Sedentary
Somewhat Active
Active
Extremely Active
Describe you current workout/exercise: walking, hiking, cardio, gym membership,
private trainer, etc.
What is your workout frequency and duration? (i.e. daily / 1hr.)
How would you rate you overall level of stress on a scale of 1 to 5 (1 is lowest and 5
is highest)?
Complementary Therapies:
Have you had any holistic alternative therapy? YES
NO
If yes, please circle what type(s):
Acupuncture, Alpha-biotic Alignments, Chiropractic Adjustments, Body Work (Deep
Tissue massage, Energy/Reiki, Maya Abdominal massage), Cranial Sacral therapy,
Herbal/Naturopath supplements therapy, Hydro-colonics, other(s)
Reason and what was the outcome of therapy?
Nutritional Behaviors: On an average day what do you eat? Describe:
What are your eating patterns (circle):
Healthy Choices: Describe types (i.e. raw, vegan, vegetarian, carnivore, organic
foods)
Fast Food(s): Describe what types and how often? Is this a lifestyle pattern?
Stress induced eating: Describe triggers (emotions attached to behavior(s)
On an average day what do you eat?
Have you ever been on a specific type of diet for health purpose? Describe:
Habit Forming Behaviors:
Do you smoke? Yes
No

If yes, how many packs per day?

Do you consider yourself a social drinker or drink excessively? Describe:
Do you use recreational drugs? Yes No
If yes, what type of recreational drugs and how often? Describe:
Do you use pain medication? Yes No
If yes, what was the reason for the prescription? What type of pain medication?
How often?
Are you addicted to any kind of substance abuse? Yes No
If yes, what kind(s) of substance abuse
Are you in recovery? Yes
No
If yes, how long?

Spiritual Awareness: Do you have a specific faith-based belief? What is it?

How do you express your belief?
How important is it to nurture and care for your spiritual well-being? On a scale
from 1 to 5 rate the level of importance it is to develop and care for your spiritual
well-being ( 1= lowest, 5 = highest)
Do you desire a deeper spiritual relationship? Yes
If yes, describe:

No

Physical and Mental Health History

Please review the following list and check condition(s) that have affected
your health either recently or in the past:
__broken/dislocated bones
__muscle strain/sprain
__arthritis, bursitis
__disc problems
__scoliosis
__back problems
__osteoporosis
__Diabetes 1 or 2
__high/low blood pressure
__insomnia
__anxiety/depression
__diagnosed mental health disorder(s)
__asthma/shortness of breath
__numbness/tingling anywhere
__cancer-describe type:
__pregnancy

__female issues-describe:
__surgery (surgeries)-describe:
__seizures
__traumatic brain injury
__strokes
__heart condition/chest pain
__auto immune deficiency conditions-describe
__fibromyalgia
__other(s) describe:
Emotional Trauma:
Have you ever been the victim of abuse? Yes No
Circle type(s) of abuse:
Physical
mental/emotional sexual neglect/abandonment
Did you receive counseling/therapy?
Do you have any trauma or crisis that entailed lost/grief? Yes No
Describe:
Did you receive counseling therapy?
Are these issues you wish to address through holistic psycho-therapy? Yes
Explain:

No

Are you currently on any type of medication? If yes, please list names and reason
for medication.
Are you currently seeing a healthcare professional? If yes, please list name and
reason/treatment.
Please list any further information that you believe would be beneficial to your
Holistic and Yoga Therapist to better assist you in meeting your health and wellness
goals.

Thank you for taking time

Would you like to get emails from other meditation opportunities in your area? (circle one)
YES

NO

Emergency Contact (name and number)_____________________________________

___________________________________________
It is MY responsibility to ask for clarifications on anything that I do not understand.
I will not put my body in any position that does not feel comfortable. If I feel any pain I will stop
immediately.
I understand this class is for me to develop an awareness of my body and will learn to heed the messages it
sends me. I agree to waive claims against any persons connected with practice for any injuries I may sustain

and assume full responsibility for all my actions related to practice. I understand and agree to the conditions set
out above.

__________________________________________________
Signature

__________________________
Date

Can you please take a moment to let us know how you became aware of the our
Foundation?
Newspaper ( ) Web-Search ( ) Friend ( ) Word of Mouth ( ) Rec. Guide (

) Yellow Pages (

) Friend Circle ( ) Ad ( )