Kayamana Consultation Form
Date:
Name:
Date of Birth:
Age:
Sex:
Select Option
Male
Female
Other
Classes:
Select Option
Online
Offline
Address
Street:
City:
State:
Zip:
Phone:
Email:
Height (cm):
Current Weight (kg):
Weight One Year Ago (kg):
Are you vegetarian or non-vegetarian?
Do you follow any diet?
How many meals a day? (e.g., 3 or 5)
Allergies (if any):
Activity History
Are you active during the day? (e.g., walking/desk job)
How is your sleep?
Select Option
Excellent
Okay
Bad
Worse
Do you have regular bowel movements?
Select Option
Yes
No
Do you exercise regularly? Describe:
Any injuries affecting exercise? Describe:
Do you smoke? If yes, how much and age started:
Do you drink alcohol? If yes, how much and age started:
Do you follow a dietary plan? Comments:
Present/Past History
Check any that apply:
Rheumatic fever
High blood pressure
Low blood pressure
Liver disease
Recent operation
Injury to back or knees
Lung disease
Kidney disease
Heart attack
Dizziness/fainting
Diabetes
High cholesterol
Explain checked items:
Family History
Check any that apply to first-degree relatives:
Heart operation
Heart disease
High blood pressure
High cholesterol
Diabetes
Other illness
Explain checked items:
Current condition and duration:
Medications you're currently taking:
Personal health and fitness objectives:
I accept and agree with the terms of the consultation, including yoga, meditation, self-massage, and nutrition guidance.
Submit
