Name
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First Name
Last Name
Pronouns
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Email
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Age
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Occupation
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Have you ever done yoga and/or worked with a yoga therapist?
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What are your current reasons for seeing a yoga therapist?
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List all current and previous health conditions. Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates.
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How long have you been experiencing this health issue?
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How does this issue impact your life?
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Who else do you currently see for your health concerns or general health promotion?
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Please list your current medications, including supplements.
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Please state the areas of discomfort in your body. Try to describe where they are located and type/degree of discomfort.
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What are your favorite physical movements and/or activities?
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What are your least favorite physical movements and/or activities?
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Do you have a regular exercise program? Please describe.
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What relieves your physical pain?
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What increases that pain?
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How is your sleep / what are your sleep habits?
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Please describe your overall energy level. Does it fluctuate or stay consistent? When are you most energized, least energized?
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Briefly state your daily routine. Consider how much of your day is spent sitting, driving, standing, lifting, lying down, working out, etc.
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If you could change one thing in your life, what would it be?
What is your current perceived stress level?
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Low
Moderate
Hight
Do you experience anxiety, sadness, and/or depression? Are there places in your body where these feelings tend to dwell when they arise?
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What relieves your emotional pain? Please be detailed if this applies to you.
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What increases your emotional pain? Please be detailed if this applies to you.
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What life challenges are you currently facing?
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What aspects of your life give you the most joy and pleasure?
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What aspects give you the least?
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Do you have a space in your home where you feel safe and comfortable? Is that a place you could practice yoga?
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What spiritual and social groups are you involved with? Who do you turn to for support?
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During our time together what goal(s) would you like to work on?
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How much time (each day/week/month) can you devote to your own personal yoga practice?
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