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Intake Form
New Client Yoga Therapy Intake Form
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Name
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Your answer
Email
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Your answer
Phone
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Your answer
Date of Birth
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YYYY
What are your current reasons for seeing a yoga therapist? Do you have a goal for our time together?
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Your answer
List your current and previous health conditions.
Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates.
Your answer
Who else are you currently seeing for your health concerns or general health promotion? How often do you see them?
Your answer
Please list your current medications, including supplements.
Your answer
Please state the areas of discomfort in your body.
Try to describe where they are located and type / degree of discomfort.
Your answer
Exercise
Do you have a regular exercise program? Please describe. What are your favorite physical movements? Least favorite?
Your answer
Diet
Briefly describe your typical diet.
Your answer
Daily Routine
Briefly state your daily routine. In percentages how much of your day is spent with the following: •Sitting •
Driving • Standing • Desk work • Lifting • Lying
Your answer
Where do you hold tension in your body?
Your answer
Indicate the pain descriptions that apply most to you.
Sharp
Dull / Achy
Localized
General
Persistent
Recurrent
Chronic
Other:
What relieves your pain? What increases your pain?
Your answer
Please describe your sleep habits.
Your answer
Please describe your overall energy level. Does it fluctuate or stay consistent? When are you most energized, least energized?
Your answer
What are your perceived stress levels?
Choose
Low Stress
Moderate Stress
High Stress
Do you experience anxiety, sadness or depression? Are there places in your body where these feelings tend to dwell when they come up?
Your answer
What life challenges are your currently facing?
Your answer
What aspects of your life gives you the most joy and pleasure?
Your answer
If you could change one thing, what would it be?
Your answer
Are you involved in or do you have any religious affiliations that you may like to include in your Yoga practice?
Your answer
How much time (each day/week/month) can you devote to your own personal yoga practice?
Your answer
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