Intake Form - Private Yoga Wellness Consultation with Ann Grace Yoga
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.
Sign in to Google to save your progress. Learn more
Email *
Name *
Age *
Profession/Occupation
What do you hope to achieve with private Yoga Wellness sessions? *
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 provide more details about checked areas above.
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Please provide more details about checked areas above.
Please review this list and check those conditions that have affected your health either recently or in the past 10 years.
Please provide more details about checked areas above.
Do you have pain or limitations in mobility in any of the following areas?
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
What kind of exercise do you engage in?
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 the source of your stress?
What do you do to counteract stress?
How often do you feel anxious?
Clear selection
How often do you feel depressed?
Clear selection
Does your current mental state impact the quality of your life? In what way?
What is your energy level right now?   *
Very Poor
Excellent
What is your typical energy level
Clear selection
When do you have the most energy?
Clear selection
Can you skip meals easily?
Clear selection
Please describe your diet - check all that apply, and there is no judgment
How many meals do you eat per day?
Clear selection
What is your sleep like? (check all that apply)
Do you have any trouble concentrating?
Do you have trouble remembering things?
Habits (there is no judgement here)
How many hours do you watch TV every week? (no judgement!)
Clear selection
Do you connect with yourself? How and how often?
What do you do for fun? Do you have hobbies?
Do you have a support network of friends and family?
What do you enjoy in your life? Where do you find joy?
How satisfied are you with the quality of your life right now?
Clear selection
Is there anything else you want to share about your body and mind that you think might be relevant?
WAIVER Private Yoga 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. *
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 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 and all other sponsoring agencies from responsibility for any injuries I may sustain as a result of participation in this program.
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.
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Team Sun Wellness. Report Abuse
Google Forms