Private Yoga Therapy Intake for Waldenstrom's
Hi there! I would love to hear how you're doing and help facilitate your further health and wellbeing using the tools of yoga. Please fill in as much as you feel comfortable sharing with me so that I can get to know you a little better. Everything you share with me will be kept confidential. Be advised that the Yoga Therapy is a complementary or integrative practice to be used in conjunction with standard medical care.
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Email *
Name *
What is today's date?
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Age
Occupation
What do you hope to achieve during our yoga therapy sessions?
Check any goals you might be interested in:
What is your current Waldenstrom's status?
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Feel free to tell me more about your WM status here, such as what treatment you are currently receiving, if any.
I experience the following most likely as a result of my Waldenstrom's or Waldenstrom's treatment (check all that apply):
If there was one, what was the main symptom that brought you to your WM diagnosis? (i.e. fatigue, peripheral neuropathy, etc.) If there was no symptom, what led to your diagnosis?
When were you initially diagnosed with WM? What else was going on in your life at that time?
Personal Yoga and Meditation Interests (check all that apply):
Do you have any physical challenges or issues you would like help with?
Do you have any psychological, emotional, or spiritual challenges or issues you would like help with?
Are you diagnosed with any medical conditions currently, beyond Waldenstrom's macroglobulinemia?
Please check those conditions that have affected your health recently, and for those checked provide more detail below.
Provide more detail for any checked responses above.
Are you currently taking any medications?
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If yes, please list names and reason for med
Any supplements?
Do you have tightness, pain, or limitation in mobility in any of the following areas?
Provide more detail for any checked responses above.
On a scale of 1-10 how would you rate your overall level of pain
Minimal
Excruciating
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On a scale of 1-5 how would you rate your overall energy level?
Very Low
Very High
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What time of day you typically have the most energy? Check all that apply
How do you rate your current level of activity?
Sedentary
Very Active
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List some of the activities you enjoy the most, or do the most of - whether they are physical exercise like walking, or manual labor like gardening.
Do you currently practice yoga? If so, how often and what type?
Do you currently practice meditation? If so, how often and what type?
On a scale of 1-10, how would you rate your level of mental distress?
Not at all
Extremely
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At what times do you experience the most mental distress or a busy mind?
On a scale of 1-10, how would you rate your level of stress?
Not at all
Extremely
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Where/how do you experience stress in your body?
What is the source of, or the triggers of stress in your daily life? Please explain briefly.
How much sleep do you get each night on average
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Which describes you best? Check all that apply
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How would you describe your current diet or meal plan? (For example, I am on the Keto diet...or I prepare most of my own meals which are low carb/high protein...or, I eat out a lot, etc)
Do you have any of the following habits? (no judgement)
What brings you joy?
Is there anything else you want to share that you think might be relevant, or provide more detail for?
WAIVER:    These yoga therapy sessions are led by a certified yoga therapist. Please inform your yoga therapist of all mental and physical health conditions you have (i.e., high blood pressure, surgery, etc.), as they may affect your practice and sessions in ways you do not expect. I acknowledge that my participation is entirely voluntary. I understand that this program and its’ yoga therapists do not diagnose diseases or any physical or mental disorders, nor do they prescribe medical treatment.  I also understand that the classes, sessions and program do not constitute medical advice or advice otherwise given by an accredited mental health therapist. I have read, understood, and agree to the content of this Professional Disclosure and Liability. I hereby release Ann MacMullan, Ann Grace Yoga and the IWMF from any and all liability related to these sessions.   *
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PLEASE TYPE NAME BELOW AS SIGNATURE: I have read the above waiver and agreement and have fully understood its contents. By signing below, I am fully agreeing to all of the above statements. *
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