Intake Form - Private Yoga Wellness Consultation with Ann
I would love to hear how you're doing and help facilitate your further health and wellbeing using the tools of yoga. Please fill in as much as you feel comfortable sharing with me so that I can get to know you a little better. Everything you share with me will be kept confidential.
* Required
Email
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Your email
Name
*
Your answer
Age
*
Your answer
Profession/Occupation
Your answer
What do you hope to achieve with private Yoga Wellness sessions?
*
Your answer
Main problem(s) or challenge(s) you would like help with? Please indicate how long you have had issue(s), and any attempted treatment/response
Your answer
What are your goals or expectations for your yoga wellness practice? (Check all that apply)
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Strength Training
Flexibility
Balance
Stress Relief
Cardiovascular Health
Improve Focus
Improve Fitness
Manage Weight
Improve Posture
Make positive behavioral changes
Complementary Care for Mental Imbalances (Depression/Anxiety)
Manage Reactivity
General Health and Happiness
Other:
Required
I would like to: (check all that apply)
Manage an illness
Rehab an injury (with Dr. supervision)
Improve sport or work performance
Other:
Personal Yoga Interests: (check all that apply)
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Slow Flow Yoga (therapeutic vinyasa)
Flow Yoga (traditional vinyasa)
Structural Alignment (Hatha Yoga)
Chair and Prop Yoga
Restorative Yoga
Yin Yoga
Concentrated rest (Yoga Nidra)
Meditation and Mindfulness
Breathing Exercises/ Pranayama
Ayurveda (Diet & Lifestyle)
Aromatherapy
Chanting/Mantras/Sound Healing
Other:
Required
Are you diagnosed with any medical conditions? Since when? What is current status?
Your answer
Were there any diseases that you suffered from earlier?
Your answer
Have you had any kind of surgery/minor procedures done on you?
Your answer
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Broken/dislocated bones
Disc issues
Osteoarthritis
Scoliosis
Osteoporosis (low bone density)
Other back issues
Numbness, tingling, neuropathy
Asthma, short breath
Anxiety
Seizures
Insomnia
Diabetes Type 1
Circulation Problems
Menopause or Perimenopausal Symptoms (abatement of period, hot flashes, mood fluctuations)
Epilepsy
Headaches
Mental Health Challenges
Other:
Please provide more details about checked areas above.
Your answer
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Muscle strain/sprain
Bursitis
High blood pressure
Stroke
Heart Conditions
Surgery
Digestive Issues
Please provide more details about checked areas above.
Your answer
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Diabetes
Auto-immune condition
Excess weight
Depression
Pregnancy
Cancer
Diabetes - Type 2
Other:
Please provide more details about checked areas above.
Your answer
Do you have pain or limitations in mobility in any of the following areas?
Neck
Shoulders
Upper Back
Lower Back
Sacrum
Hips
Elbows
Knees
Hands
Feet
Wrists
Ankles
None of the Above
Other:
On a scale of 1-10, how would you rate your level of pain, if any?
Barely any pain at all
1
2
3
4
5
6
7
8
9
10
Pain all the time
Clear selection
What is the main source of your pain, if any?
Your answer
What prescription medications are you taking now? (Since when?)
Your answer
Are you taking any herbal or alternative medicine? (What and since when?)
Your answer
How do you rate your current level of activity?
*
Sedentary
1
2
3
4
5
Very Active
What kind of exercise do you engage in?
None
Walking
Running
Biking
Swimming
Weightlifting/Strength Training
Aerobics
Yoga
Other:
How often do you break a sweat with exercise? (times/week)
None
0
1
2
3
4
5
6
7
Every Day
Clear selection
Do you currently practice yoga? If so, what type and how often?
*
Your answer
On a scale of 1-10, how would you rate your level of stress?
*
Not at all stressed
1
2
3
4
5
6
7
8
9
10
Very Stressed
How does stress manifest or feel in your body and mind?
Your answer
What is the source of your stress?
Your answer
What do you do to counteract stress?
Your answer
How often do you feel anxious?
Never
Rarely
Sometimes
Often
All the time
Clear selection
How often do you feel depressed?
Never
Rarely
Sometimes
Often
All the time
Clear selection
Does your current mental state impact the quality of your life? In what way?
Your answer
What is your energy level right now?
*
Very Poor
1
2
3
4
5
6
7
8
9
10
Excellent
What is your typical energy level
Low
Medium
High
Inconsisten
Clear selection
When do you have the most energy?
Early morning
Late morning
Early afternoon
Late afternoon
Early evening
Late evening
In the middle of the night
Clear selection
Can you skip meals easily?
Yes
Sometimes
No, I get irritable or angry
No, I get lightheaded
Clear selection
Please describe your diet - check all that apply, and there is no judgment
I eat my meals at mostly the same times each day
I often find myself eating more than I'm hungry for (comfort eating)
I eat a lot of veggies and fruit
I eat a lot of processed food
I eat a lot of animal protein
I cook/prepare most of my own meals
I don't have much time to cook/prepare my own food
I eat to live
I live to eat
How many meals do you eat per day?
1
2
3
4
5
More than 5
Clear selection
What is your sleep like? (check all that apply)
I don't need much sleep to function
I have insomnia regularly
I am a sound sleeper and have no trouble sleeping usually
I fall asleep easily but once I wake up I have a lot of trouble getting back to sleep
I don't fall asleep that easily
I go to bed a roughly the same time every night
I get between 4-6 hrs per night
I get between 6-8 hrs per night
I get between 8-10 hrs per night
Other:
Do you have any trouble concentrating?
Never
Rarely
Sometimes
Often
All the time
Do you have trouble remembering things?
Never
Rarely
Sometimes
Often
All the Time
Habits (there is no judgement here)
Alcohol
Coffee
Tea
Tobacco
Marijuana
Other:
How many hours do you watch TV every week? (no judgement!)
0
1
2
3
4
5
6
7
8
9
10
Clear selection
Do you connect with yourself? How and how often?
Your answer
What do you do for fun? Do you have hobbies?
Your answer
Do you have a support network of friends and family?
Yes
No
Sometimes
I act as support to others, more than I receive support
What do you enjoy in your life? Where do you find joy?
Your answer
How satisfied are you with the quality of your life right now?
Completely
Moderately
Somewhat
Not really
Not at all
Clear selection
Is there anything else you want to share about your body and mind that you think might be relevant?
Your answer
WAIVER Welcome to Team Sun Wellness. Team Sun Wellness is a holistic approach to yoga that incorporates Yoga Therapy practices. I (ANN MACMULLAN) am not a licensed physician, nor are Yoga Therapy services licensed by the state. Our method of treatment in Yoga Therapy is alternative or complementary to conventional medicine. If you ever have any concerns about the nature of your services, please feel free to discuss them with us. We recommend that you inform your medical doctor that you are receiving these services. I have read and understood the above disclosure about the services and I have discussed the nature of the services to be provided.
*
I have read and understood the above disclosure
Required
I understand that Ann MacMullan is not licensed physician and that services rendered are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor.
I have read and understood the above disclosure
I understand that Yoga Therapy services incorporate both cognitive and physical approaches, and that there is an inherent risk when participating in physical activities. I agree to let the therapist know of any physical limitations I might have, or any physical activities I do not wish to participate in.
I have read and understood the above disclosure
I hereby release Ann MacMullan, Team Sun Wellness, LTD and all other sponsoring agencies from responsibility for any injuries I may sustain as a result of participation in this program.
I have read and understood the above disclosure
Clear selection
Cancellation policy: There will be no charge if appointments are cancelled 24 hours in advance. Cancellations with 24 hours of the scheduled time will be charged the full fee.
I have read and understood the above disclosure
Clear selection
PLEASE TYPE NAME BELOW AS SIGNATURE: I have read the above waiver and agreement and have fully understood its contents. By signing below, I am fully agreeing to all of the above statements.
Your answer
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