Yoga for Cancer:

CONFIDENTIAL INTAKE FORM


WELCOME! The following information is requested to allow us to provide an effective and enjoyable yoga experience. If at any time you have questions regarding your session, please let us know.  

If you have any questions or concerns, please contact Jessie Lu, jgalbraith@whatcomymca.org

Age
Gender
Identify As
Race/Ethnicity

Please let us know a little about your cancer journey in order for us to provide modifications if necessary.

Why are you taking this class? (check all that apply)
How often do you practice yoga?
Have you practiced yoga before?
What are your goals or benefits you are looking for?
Are you a cancer (check all that apply)
If you are a patient or survivor, do you currently have a pic line, port or other device?
Do you have any physical challenges/injuries you are managing?
Sign above