New Client Intake form Name * First Name Last Name Email * Address * Age * Occupation Phone * (###) ### #### Do you have or have you had any of the following: * Select all that apply: High Blood Pressure Unstable joints Glaucoma Joint dislocation Osteoporosis Metal implants/artificial joints Seizures Bladder or bowel problems Diabetes Pinched nerves or discs Rheumatoid Arthritis Sciatica Anemia Broken bones Heart problems Allergies Asthma Headaches Other breathing problems Visual difficulties Dizziness, vertigo or loss of balance Chest pain Unexplained falls of fractures Night sweats Hearing difficulties Joint swelling Hernias or ruptures Traumatic accidents Major surgeries Other chronic conditions Back problems Joint problems Epilepsy Fibromyalgia Arthritis Low blood pressure Hypoglycemia Chronic Fatigue Cancer Motor Vehicle Accidents Anxiety Depression Snoring/Sleep Apnea Chronic Coughing Frequent Sighing/Yawning/Sniffing Tightness in Chest Other 2. Do you experience pain in any part of your body – on occasion, acute or chronic? * Please list any surgeries (include dates) * Women only: * Hysterectomy? Menopause challenges? Menstruation? Pregnant? Have you been under the care of a licensed health care professional in the past year? If so, for what? * Please list any medications and supplements that you are taking * Have you experienced other health problems or challenges in your life? * This is very important: Please mention any other health or medical condition that you believe may be helpful to your instructor with regard to any precautions that should be taken to ensure your well-being. * What is the primary condition (s) that you are seeking support for through yoga therapy today? * What time do you wake up? * What do you eat for breakfast, on a typical day? * What activities do you include in your morning routine? * What do you eat for lunch? * What activities do you include in your afternoon routine? * What do you eat for dinner, on a typical day? * What activities do you include in your evening routine? * What time do you usually go to sleep? * List regular practices that are not included in the above schedule, e.g., exercise, meditation, spiritual practices, etc. Please include any other comments about your daily routines. * How is your diet and appetite? * Bowel movements * Regular Irregular Urination * Frequent Normal Do you have gas or bloating? * Yes No Any current or past problems with chronic eating disorders or other food related issues? * Do you have allergic reactions to any substances? If yes, please list. How many cups of caffeinated beverages do you drink per day? Type(s) of beverage: Coffee Tea Soda How many cups of non-caffeinated beverages do you drink per day? * Type(s) of beverage: Herbal tea Milk Juice Other How much water do you drink per day? * Do you smoke or drink? If so, how much per week? * Any current or past problems with addiction or substances? * How would you describe your breathing? * How would you describe your energy levels? Is your overall energy stable or quite variable? * Body temperature: Do you generally run warm or cold? Please explain. * Do you prefer hot or cold weather? * How is your stress level? * What types of situations trigger stress or bring it on for you? * What are some of the ways you find most effective for releasing stress? * Sleep: Do you awaken from sleep feeling rested? Do you fall asleep easily? Do you wake frequently in the night? If so, why? (ie: to urinate; thought/worries; pain) * What is your family and/or community life like? * What do you do to bring joy, peace, health and balance into your life? * How well do you feel you nourish yourself – with food, love and laughter? * How would you describe your state of mind most of the time? * How would you describe your spiritual or religious life? * What is your experience with Yoga, meditation or other spiritual practices? * How often do you practice and is your practice regular? * What have you found most beneficial from these practices? What have you found the most difficult or challenging? * Have you had any previous Yoga injuries? How did they happen? * What do you hope to get out of Yoga practice? What is your main goal for Yoga Therapy? * Do you have any additional comments/questions/concerns you’d like to address? * Electronic signature * By checking this box and typing my name below, I am electronically signing this consent form * Yes, I consent No, I do not consent Please enter today's date: * Thank you!
