Yoga Therapy Intake Form
The following CONFIDENTIAL information will help me understand your specific needs when we begin to work together. Thank you for taking the time to fill it out in as much detail as possible. This should take approximately 15-20 minutes. It's a valuable investment for the work we'll be doing together. Many thanks.
CONTACT INFORMATION
Name *
Your answer
Phone number *
Your answer
Email *
Your answer
Address *
Your answer
Age *
Your answer
Today's date:
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PERSONAL DETAILS
What are your reasons for seeing a yoga therapist?
Your answer
List the current & previous health conditions that I should be aware of. Please include medical diagnoses, surgeries, accidents, injuries etc..., and approximate dates.
Your answer
How long has your current health issue been going on?
Your answer
What other professionals are you currently seeing for this health issue? How often do you see them?
Your answer
Please list the current medications you are taking, including supplements.
Your answer
On a typical day, where do you tend to hold tension in your body?
Your answer
Please describe areas of pain in your body. Be as specific as possible; where do you feel pain, does it radiate to other parts of the body? Does it feel superficial or deep?
Your answer
If your pain could talk to you, what would it tell you?
Your answer
What movements or actions relieve your pain? Think about ranges of motion, or specific movements (reaching, bending over, twisting, picking things up, sitting, walking etc.)
Your answer
What movements or actions increase your pain? Think about ranges of motion, or specific movements.
Your answer
Do you have a regular exercise program? What is your favorite physical activity? Least favorite? What outdoor activities do you enjoy?
Your answer
Do you have any difficulty with your breathing? Do you notice any changes in your breath when you become upset or agitated?
Your answer
Briefly describe your typical diet. How is your digestion?
Your answer
Are you, or have you ever been a smoker?
Your answer
Do you drink tea, coffee, alcohol? How much each day?
Your answer
Describe your sleep habits.
Your answer
On an average day, describe what percentage of your time is spent sitting at a desk? standing? driving? lifting heavy items? in a strained posture?
Your answer
Describe your overall energy level. Are there times of the day where you are most energized? Least energized?
Your answer
What is your perceived stress level? low, moderate, high?
Your answer
Do you experience anxiety or depression? Both? Describe briefly. Has this condition been diagnosed by a doctor?
Your answer
Are there places in your body where you "feel" your emotions when they come up?
Your answer
Are there specific life challenges you are currently facing, that you can share with me?
Your answer
Describe a natural scene that you can easily visualize as being soothing, joyful, inspiring? Describe the sights, sounds, feelings in this place.
Your answer
What aspects of your life bring you the most joy or pleasure?
Your answer
Have you considered, or are you currently volunteering your time or talents?
Your answer
Yoga history
Do you currently practice yoga or meditation? If yes, please indicate how much time you devote to your practice daily or weekly.
Your answer
What have you found most beneficial from your practice?
Your answer
What is the most challenging?
Your answer
Have you had any previous yoga injuries? How did they happen?
Your answer
Comments
Do you have any additional comments or other information that you'd like to share with me?
Your answer
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