Phone #:    



Emergency contact:                  

Phone #:

Diagnosis (Please include type of cancer, stage, and lymph node involvement):


Date of Diagnosis:


Date of last chemotherapy:                              How many treatments remain?

Date of last radiation:                                        How many treatments remain?


Please describe any side-effects you are currently experiencing from radiation, chemotherapy, and other therapies:











Please list all cancer-related surgeries, as well as other major surgeries you have had.

​Date      Surgery

Please describe any limitations/side effects you are currently experiencing from any of the surgeries:

Please list any other health problems you are experiencing, particularly those for which you are 1) taking medication, and/ or 2) being monitored (on an occasional or regular basis) by a doctor:


Besides what you have listed, do you have any other limitations in your physical activity level, or any movement that causes pain?

Are you interested in restoring strength and flexibility to a particular area of your body, please list below:

Are you able to do the following with relative ease and comfort?



         Breathe through nose:

         Lie on your back:

         Lie on your stomach:

         Lie on your right side:

         Lie on your left side:

Aside from what you have listed, has your doctor modified your physical activity level, or restrict/limit your movement in any way? If so, please explain:


Have you practiced yoga before?

What is your goal for participating in yoga classes?


Do you have special concerns about participating in class?

How did you find out about Yoga for Cancer & Welcome Mat Family Yoga?

I _____________________________________ (print name), understand that yoga includes physical movement as well as an opportunity for relaxation, stress reduction and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the teacher. I will not practice through pain or push myself beyond my limits.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I affirm that my platelet count is at least 20,000, all surgical incisions are healed and I can move about independently. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Welcome Mat Family Yoga, any other yoga & cancer teachers, or the facility where class is held.

____________________________________________       ______________

(Signature of student/parent or guardian)                             Date