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.
Name *
Phone number *
Email *
Address *
Age *
Today's date:
What are your reasons for seeing a yoga therapist?
List the current & previous health conditions that I should be aware of. Please include medical diagnoses, surgeries, accidents, injuries etc..., and approximate dates.
How long has your current health issue been going on?
What other professionals are you currently seeing for this health issue? How often do you see them?
Please list the current medications you are taking, including supplements.
On a typical day, where do you tend to hold tension in your body?
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?
If your pain could talk to you, what would it tell you?
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.)
What movements or actions increase your pain? Think about ranges of motion, or specific movements.
Do you have a regular exercise program? What is your favorite physical activity? Least favorite? What outdoor activities do you enjoy?
Do you have any difficulty with your breathing? Do you notice any changes in your breath when you become upset or agitated?
Briefly describe your typical diet. How is your digestion?
Are you, or have you ever been a smoker?
Do you drink tea, coffee, alcohol? How much each day?
Describe your sleep habits.
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?
Describe your overall energy level. Are there times of the day where you are most energized? Least energized?
What is your perceived stress level? low, moderate, high?
Do you experience anxiety or depression? Both? Describe briefly. Has this condition been diagnosed by a doctor?
Are there places in your body where you "feel" your emotions when they come up?
Are there specific life challenges you are currently facing, that you can share with me?
Describe a natural scene that you can easily visualize as being soothing, joyful, inspiring? Describe the sights, sounds, feelings in this place.
What aspects of your life bring you the most joy or pleasure?
Have you considered, or are you currently volunteering your time or talents?
Yoga history
Do you currently practice yoga or meditation? If yes, please indicate how much time you devote to your practice daily or weekly.
What have you found most beneficial from your practice?
What is the most challenging?
Have you had any previous yoga injuries? How did they happen?
Do you have any additional comments or other information that you'd like to share with me?
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