Home Yoga Therapy Intake Form
Yoga Therapy Intake Form
First Name
Last Name
Daytime Phone
Home Phone
Email *
Age
Handedness
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 has your current health issue been going on?
Have you consulted with health care providers and if so, who? What is their take on your 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?
On a scale of 1 to 10, with 10 being the highest level of pain, how does your pain feel now? This morning? Last night? Last week? A month ago?
Describe where your pain is: What direction do you feel it in, where does it start and end? What is the shape and size and depth of the pain? Is it superficial or deep? Does it feel like muscle, bone, nerve, connective tissue, scar tissue? Be detailed.
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? How about postural pressure, when you twist, sit, lean on it?
If your pain was wise and could talk with you, what would it say to you?
What relieves your pain? What increases your pain? Think about ranges of motion, movements etc.
Indicate the pain descriptions that apply most to you.
What exercises feel good and safe for you? What exercises feel bad and unsafe for you?
What functional movements and tasks are difficult for you? Reaching, bending over, twisting, picking things up, sitting for long periods of time, walking up the stairs, hiking on uneven terrain?
What do you like to do for exercise, how many times a week do you exercise and how long do you exercise each 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, and hip imbalances?
What kind of work do you do? Are you comfortable at work?
Explain your diet. Share what you eat and drink in a typical week. How much water intake do you have each day?
Is your daily schedule regular or does it change from day to day?
Any difficulties with 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 and if so, how much each day?
What is your usual energy level? Is your energy level stable or variable? Do you feel yourself crash during the day? If so, what time of day?
How would you describe your stress level? Low, moderate, high or off the chart stressed out?
Do you experience anxiety, sadness or depression?
Are there any emotions you have difficulty processing, feeling, expressing or validating? Where do you feel your emotions in your body? Describe yourself in 3 emotions.
How do you express yourself creatively? Singing, journaling, writing, dancing, art?
Are your personal relationships healthy and nurturing?
Is your career nurturing and supportive?
What life challenges are you currently facing?
Describe a natural scene that you could easily visualize as being healthy, inspiring, soothing, healing, joyful and spiritual grounding. What sounds, sights, fragrances, feelings inspire you?
Do you keep bumping up against the same problems and situations in life?
Are there habits you would like to change physically, energetically, emotionally, mentally, spiritually?
Have you considered or are you currently volunteering your talents and time?
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 calling?