Intake Form Yoga Therapy Intake Form Yoga Therapy Intake Form Name * First Last * Last Email * Address * Address Line 2 Cell Phone Number * City * State * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Postal Code Handedness Left Right What are your major health concerns today? Do you have any current or previous medical conditions? Please include surgeries, accidents, injuries, diseases, other relevant conditions. How long have your current health issues been going on? Have you consulted with health care providers and if so, who? What is their take on the situation? Please be as detailed and accurate as possible. Contact your health care providers prior to our session if you do not understand their diagnosis. Are you taking prescription or non-prescription medications and, if so, what are they and what are they for? What natural supplements are you taking? Please be specific: Describe where your pain is, what direction you feel it in, where it starts and ends. What is the shape and size and depth of your pain? Is it superficial or deep? Does it feel like muscle? Bone? Nerve? Connective tissue? Scar tissue? Are you experiencing referred pain - radiating pain down your limbs, hands, feet, in your neck or head? How does the area of pain feel when you touch it? Tender? Inflamed? Swollen? Dull? Sharp? What about postural pressure - when you twist, sit, stand, drive, lean on it? If your pain was wise and could talk to you, what would it say? What relieves your pain? What increases it? Think about ranges of motion, movements, etc. Which exercises feel good and safe for you? Which feel bad and unsafe? What functional movements and tasks are difficult for you? Reaching? Bending over? Twisting? Picking things up? Sitting for long periods of time? Walking up stairs? Hiking on uneven terrain? What do you like to do for exercise? How many times a week do you exercise and how long per session? What outdoor activities do you enjoy? Are you satisfied with your posture? Are you aware of any imbalances in your body such as shoulder, spine or hip? What kind of work do you do? Are you comfortable while working? Explain your diet. What do you eat and drink in a typical week? How much water do you drink each day? Is your daily schedule regular or does it change from day to day? Do you have any difficulty breathing? Do you notice changes in your breath when you become upset or agitated? Are you or have you been a smoker? Do you drink tea, coffee or alcohol? How much each day? What is your usual energy level? Is it stable or variable? Do you feel yourself crash during the day? Is so, at what time? How do you rate your stress level? (5 is highest) 1 2 3 4 5 Do you experience anxiety, sadness, or depression? Please include details. Are there any emotions you have difficulty processing, feeling, expressing, validating? Where do you feel emotions in your body? What are they? Are your personal relationships healthy and nurturing? Why or why not? What changes would you like to see? Is your career nurturing and supportive? Why or why not? What changes would you like to see? What life challenges are you currently facing? Describe a natural scene you can easily visualize as being healthy, inspiring, soothing, joyful, spiritually grounding. What sounds, sights, fragrances, feelings inspire you? Do you keep running up against the same problems and situations in life? Are there habits you would like to change physically, energetically, emotionally, mentally, spiritually? What are they? Have you considered or are you currently volunteering your time or talents? How would you describe the spiritual dimension of your life? Do you feel connected to something larger than yourself? What are you passionate about? What is your life's calling? What are your goals for yoga therapy? Comments BREAST CANCER SECTION (optional) arrowup6 Date of Diagnosis Doctor(s) Date of Last Chemotherapy Number of chemotherapy treatments remaining Date of Last Radiation Number of radiation treatments remaining Describe any limitations you are currently experiencing from any surgeries. List any other health problems you are having, particularly those related to medication or those that are being regularly monitored by a doctor. reCAPTCHA Submit
