Custom Yoga

at Healing Arts

420 E. 81st Street

New York, NY 10028

Dr. Zev Roizer: (917) 697-5969

Simone Lindner (212) 501-4863

Name

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Address

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Age (optional)

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Profession

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Reason why you want to do yoga

(What do you want to get out of this experience?):

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Have you done any movement classes before?  Do you practice yoga now?  What type?

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If yes, what were your experiences?

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Are you currently seeing Simone Lindner and or Dr. Zev Roizer?

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If you are doing the KMI sessions, in what session are you?

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Do you have a medical history? (e.g. car accident, whip lash or anything you think is important for us to know)

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Where do you feel most of the strain in your body?

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For Practitioners Only

Client/Patient of __________

Notes from Practitioners: