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.
Email address *
Name *
Age *
Profession
What do you hope to achieve with your private Yoga Wellness consultation today? *
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
What are your goals or expectations for your yoga wellness practice? (Check all that apply) *
Required
I would like to: (check all that apply)
Personal Yoga Interests: (check all that apply) *
Required
Are you diagnosed with any medical conditions? Since when? What is current status?
Were there any diseases that you suffered from earlier?
Have you had any kind of surgery/minor procedures done on you?
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
On a scale of 1-10, how would you rate your level of pain, if any?
Barely any pain at all
Pain all the time
Clear selection
What is the main source of your pain, if any?
What prescription medications are you taking now? (Since when?)
Are you taking any herbal or alternative medicine? (What and since when?)
How do you rate your current level of activity? *
Sedentary
Very Active
How often do you break a sweat with exercise? (times/week)
None
Every Day
Clear selection
Do you currently practice yoga? If so, what type and how often? *
On a scale of 1-10, how would you rate your level of stress? *
Not at all stressed
Very Stressed
How does stress manifest or feel in your body and mind?
What is your energy level? *
Very Poor
Excellent
Can you skip meals easily?
Clear selection
Diet / Nutrition - check all that apply
What is your sleep like? (check all that apply)
Habits (there is no judgement here)
How many hours do you watch TV every week?
Clear selection
Do you connect with yourself? How and how often? (List hobbies / music / meditation / community service etc)
Is there anything else you want to share about your body and mind that you think might be relevant?
SIGN WAIVER by typing your name below: Welcome to Team Sun Wellness. Team Sun Wellness is a holistic approach to yoga that incorporates Yoga Therapy practices. I 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 I have discussed the nature of the services to be provided. 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 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 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. 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 the above waiver and agreement and have fully understood its contents. By signing below, I am fully agreeing to all of the above statements. *
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