Subtle Yoga Therapy - Client Intake
Please set aside some time (approx 20 min) and complete this for to the best of your ability. Client confidentiality will be maintained at all times. The information provided on this questionnaire may only be disclosed with the express written consent of the individual named herein or, if under the age of 18, his or her legal guardian.
Today's Date *
MM
/
DD
/
YYYY
Are you a new or existing customer? *
CONTACT INFORMATION
Your name *
Your answer
Address *
Your answer
Phone number *
Your answer
E-mail *
Your answer
Preferred contact method *
Required
Emergency Contact *
Your answer
PERSONAL INFORMATION
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Height
Your answer
Weight
Your answer
Age *
Your answer
Ethnicity
Your answer
What Do You Do For Work?
Your answer
Do You Find it Stressful? Describe:
Your answer
Relationship Status
Partners Name
Your answer
Is There Anything About Your Relationship That You Want to Share?
Your answer
PHYSICAL ACTIVITY & YOGA PRACTICE
How Do You Rate Your Current Level of Activity? *
Sedentry
Extremely Active
Describe Your Current Workout/Exercise Routine *
Your answer
What is Your Previous Experience with Yoga, Meditation, Complementary, Alternative and Healing?
Your answer
Have You Every Practiced Yoga Before? *
If Yes, Date and Style of Last Practice
Your answer
How Often Do You Practice Yoga? (daily, weekly, monthly)
Your answer
Styles Most Practiced or Preferred?
Your answer
Do You Practice at a Studio?
Your answer
Do You Have a Home Practice?
What Do You Find Most Challenging?
Your answer
What Do You Enjoy Most About Your Yoga Practice If You Have One?
Your answer
What Primary Reasons - Goals or Intentions for Coming to Yoga Therapy? *
Your answer
Is There Anything Else That You Want To Share With Us?
Your answer
LIFESTYLE HABITS & WELLNESS BEHAVIORS
How Would You Rate Your Overall Stress *
No Stress
Extreme Strees
Have You Worked With Any Other Holistic Practitioners or Complementary Therapies Within the Last Year?
If Yes, What Type?
Your answer
If Yes, Reason & Outcome
Your answer
Life in General
Your answer
Which Aspects of Your Life Do You Experience The Most Stress? (work, home, etc)
Your answer
Which Aspects of Your Life Gives You the Most Joy & Pleasure? (work, home, etc)
Your answer
What Strategies Do You Use To Manage Stressful and Emotional Situations?
Your answer
If Yes, Do You Use Them Consistently?
How Do You Express Yourself Creatively?
Your answer
Briefly Describe Your Passions and Intrests
Your answer
Is There Anything About Your Family Relationships That You Would Like To Share?
Your answer
HABIT FORMING BEHAVIOURS
Do You Smoke?
If Yes, How Many Packs a Day?
Your answer
Do You Drink?
If Yes, How Often?
Is There Anything Further You Wish to Add?
Your answer
Do You Use Recreational Drugs?
If Yes, What Type of Recreational Drugs and How Often? Describe:
Your answer
Are You Addicted or Have Any Type of Substance Abuse Problems?
If Yes, What Kind(s) of Substance Abuse
Your answer
Are You In Recovery?
If Yes, How Long?
Your answer
Is There Anything Further You Wish to Add?
Your answer
SPIRITUAL AWARENESS
Do You Have a Specific Faith Based Belief? If So What Is It?
Your answer
Do You Consider Yourself a Spiritual Person?
How Do You Express It?
Your answer
How Important Is It For You To Nurture & Care For Your Spiritual Well-Being?
Lowest
Highest
Do You Desire I Deeper Spiritual Relationship?
If Yes, Describe:
Your answer
PHYSICAL HEALTH
Please Select Appropriately
Currently Expereining
Previously Experinced
N/A
Neck/Back/Joint Pain
Stiffness
Fibromyaglia
Arthritis/Bursitis
Accidents/Physical Trauma
Overuse Syndrome (RSI)
Spinal or Disc Herniations
Back Problems
Lung Issues
Allergies
High Blood Pressure
Low Blood Pressure
Hearth Palpatations
Heart Murmur
Bruise Easily
Insomnia
Circulation Problems
Over or Underweight
Siezures
Headaches
Migraines
Depression
Anxiety
Diarreah
Constipation
Hemorioids
HBS/Diabetes
Thyroid Issues
Pregnancy
Men: Prostrate
Brain Injury
Any Surgery, Acute or Chronic Illness?
Your answer
How Would You Describe Your Overall Health?
Your answer
Are You Using Contraception? If Yes Please Describe
Your answer
Medications - Over the Counter & Prescribed
Your answer
DIETARY INTAKE
Vitamins, Minerals or Herbal Supplements
Your answer
What Is Your Dietary Lifestyle
Any Known Food Sensitivities or Intolerance?
Your answer
Please Describe Your Diet. Please Give An Example of Breakfast, Lunch & Dinner
Your answer
How Is Your Digestion? Do You Experience Any of the Following After Eating?
Always
Often
Occasionally
Rarely
Gas
Bloating
Acid Reflux
Nasuea
Heaviness
Other
Is There Anything Further You Wish To Add?
Your answer
How Much Water Do You Drink In A Day? (oz)
1 ounce
10 ounces
Are You Happy With Dietary Habits?
ENERGY LEVELS
Do You Ever Experience Your Energy Level as Any of the Following? (Please select all that apply and list any others relevant to you)
Does Your Energy Fluctuate or Is It Constant?
Your answer
When is Your Energy At Its Highest?
Your answer
When is Your Energy At Its Lowest?
Your answer
What Is Your Energy Like You First Wake-Up?
Your answer
On Average How Long Do You Sleep At Night?
Your answer
Do You Struggle With Insomnia or Going To Bed? Explain:
Your answer
EMOTIONS
Do You Struggle With Any Of The Following Emotions In Your Life?
Anything to Add?
Your answer
Have You Ever Been Diagnosed With A Mental Health Condition?
If Yes, Please Explain:
Your answer
LIFE EVENTS
What Does A Day In Your Life Look Like? Please Outline Your Daily Schedule:
Your answer
Please List Any Major Life Events Within The Last 10 Years.(Include: births, deaths, accidents, moves, job changes, miscarriages, illness, or anything else that you feel has greatly impacted you)
Your answer
Is There Anything Further You Want to Share?
Your answer
THANK YOU!
Submit
Never submit passwords through Google Forms.
This form was created inside of Health4Life Coaching. Report Abuse - Terms of Service