Jeffrey Sargent Yoga Therapy Initial Intake Questionnaire
All information will be held confidential between the yoga therapist (Jeffrey Sargent) and the client, and will only be shared with medical and other health professionals afte the client's consent.
Full Name *
Your answer
Birthday *
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Sex *
Today's Date *
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Email address *
Your answer
Phone number *
Your answer
Home Address *
Your answer
Emergency Contact Info *
Your answer
What motivated you to seek private yoga therapy instruction? Do you have any specific concerns on which you would like to focus our attention? *
Your answer
Top 3 goals for yoga therapy. *
Your answer
Have you received or are you currently undergoing medical treatment for any injury or conditions pertinent to your decision to seek professional yoga therapy? *
Your answer
If so, have you discussed with your licensed healthcare provider the range of complementary approaches, such as yoga, that may be appropriate to support your current treatment program?
Please note if you are taking any prescribed medications and the date of your last medication evaluation with your healthcare provider. (For example, "blood pressure meds, hypertension; 00/00/00.) *
Your answer
Collaboration among healthcare providers can lead to a more thorough approach to your care. May we have your permission to contact other members of your healthcare team if needed? (If yes, we will provide you with a disclosure form as needed.) *
How would you describe your current state of physical health? Please specify areas where you experience physical sensations such as pain, numbness or tingling, and/or compromised mobility.
Your answer
Occupation / How long?
Your answer
Level of job satisfaction
I hate my job
I absolutely love my work
How Stressful is your Work?
No Stress
Extremely Stressful
Describe your relationship status.
Your answer
How Stressful is Your Social/Family Situation?
No Stress
Extremely Stressful
How Stressful is Your Current Health Status?
I'm in Great Health
My Health Status is a Major Cause of Concern For Me.
What is your level of pain today?
No pain
Worst pain of my life
Please select anything you are currently experiencing
Neck/Back/Joint Pain or Other Trouble
Stiffness
Fibromyalgia
Osteoporosis
Arthritis
Musculoskeletal
Previously Had Issues With
Please select anything you are currently experiencing
Lung Issues
Allergies
Respiratory
Previouisly Had Issues With
Please select anything you are currently experiencing.
High Blood Pressure
Low Blood Pressure
Heart Palpitations
Heart Murmur
Cardiovascular
Previouisly Had Issues With
Please select anything you are currently experiencing.
Headache
Migraine
Seizure
Insomnia
Depression
Anxiety
OCD/ADD
Sexual Trauma
PTSD
Neurological
Previously had Issues With
Please select anything you are currently experiencing.
Diarrhea
Constipation
IBS/IBD
Gastrointestinal
Previously Had Issues With
Please select anything you are currently experiencing.
Low Blood Sugar
High Blood Sugar/Diabetes
Thyroid Issues
Endocrine
Previously Had Issues With
Please select anything you are currently experiencing.
Breast Issues
Pregnant/Possible Pregnanacy
PMS/premenstrual dysphoric disorder (PMDD)
Peri/Post Menopausal
Men: Prostate Issues
Gynecological/Urological
Previously Had Issues With
How would you describe your dominant emotional state and how long have you felt this way? For example, "On most days, I feel depressed, anxious and confused. I have felt this way for about a year." - or - "On most days, I feel overwhelmed but optimistic. I have felt this way for as long as I can remember."
Your answer
Please describe your current level of physical activity.
Your answer
Describe your previous experience with yoga and meditation
Your answer
Please describe your current dietary habits.
Your answer
Please describe your current sleep habits and patterns. Do you wake feeling rested? When are you most full of energy? Morning Person or Night Owl?
Your answer
Do you currently consume alcohol, use tobacco, or recreational drugs? If yes, to what extent? Do you have any concerns regarding any consumption or use of alcohol, tobacco, and drugs?
Your answer
Do you currently identify with a religious, spiritual or other faith-based tradition or practice?
Your answer
Do you have a significant other? If so, how long have you been in relationship?
Your answer
Do you have a network of friends and family that provides you with satisfying social and emotional support?
Your answer
What is your passion in life?
Your answer
Is there anything else you would like to share about yourself?
Your answer
Consent to Services *
Required
Acknowledgement of Understanding: I understand that yoga includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I acknowledge that yoga is an exploration of a person’s physical and mental potential, and that my participation in yoga class or private session can cause serious injury, property damage, or potential death. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the therapist. I will continue to breathe smoothly. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. With a full understanding of the potential risks, I hereby assume the risks of participating in yoga therapy. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably waive, release and discharge any claims and/or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of the persons or entities listed below, that I have now or hereafter may have against the following persons or entities: Jeffrey Sargent and agents of the above. I agree to not sue any of the persons or entities listed above for any of the claims or liabilities that I have waived, released or discharged herein. I indemnify and hold harmless the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions. I understand the above information and guarantee that this form was completed correctly to the best of my knowledge. I know that it is my responsibility to inform Jeffrey Sargent of any changes. *
Required
Print name to accept terms listed above and serve as digital signature *
Your answer
Signature: to be signed in person during first session
Your answer
Today's Date *
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