Yoga Therapy Questionnaire
Yoga therapy promotes self motivated healing through a daily practice. This daily practice is meticulously prescribed by a Yoga Therapist in collaboration with the individual. Yoga Therapy focuses on an individuals symptoms, causes and goals. The daily practice integrates tools such as breathing, movement, meditation, mantras and mudras. Your Yoga Therapist will be in touch once this form is completed.
Check the conditions that apply to you or to any members of your immediate family (please specify later details in fields below if applicable):
High / low blood pressure
None of the above
Date of Birth
Are you currently taking any medication?
Are you taking any vitamins? If so, for what and for how long.
Describe any conditions/illness's/injuries you are currently experiencing or any accidents you have had... (Everything counts in your health picture, if you are unsure to include something please include it as long as you feel comfortable.)
*Please rate your pain from 1-10 (1 being mild 10 being severe) and describe what time of day is better/worse as well as what makes it feel better/worse.
Have you had any surgeries?
Any ever in your life?
How long have you been dealing with this pain/tension/etc.?
Are you currently seeing any other health practitioners?
If more than one just include on the last information question
What areas in life that are the most stressful currently?
Rate your current mental health 1 (I am suffering)- 10 (I am thriving)
Identify any (or a few) supporters that you have.
This could be friend/spouse/family member/colleague/practitioner etc.
What activities bring you joy/provide you with a creative and connecting outlet?
How is your water intake?
Amazing I drink a lot!
Are you on any diets currently?
Rate your satisfaction with your diet currently: 1 (poor diet) - 10 (being very healthy)
How is your digestion?
How often do you consume alcohol?
How is your sleep?
Difficulty getting to sleep
Difficulty staying asleep
Having crazy dreams and don't feel refreshed in the morning
Some nights okay some nights not great
Lovely deep sleep every night wake feeling refreshed
How are your energy levels throughout the day?
example: high in the morning but low in the afternoon/good throughout the whole day/low in the morning but high in the afternoon etc.
Are you currently exercising? If so, what are you doing/how often?
This includes walking/dancing/hiking anything active!
Experience (if any) with yoga :)
This could be the name of a class you once went to or the school of yoga you have studied
Pick what your daily movement most aligns with...
Primarily standing/walking around/active
Primarily sitting (at a desk)
Primarily lying down
Mix of standing/sitting
Primarily lifting/moving things
How much time (realistically) do you have for your daily practice?
If yoga therapy was successful for you, what would your life look like?
This can be a short answer or a long answer!
Anything else relevant you would like to share - I look forward to seeing you soon :)
While the interventions provided in my daily practice are professionally prescribed by Always Sunny Yoga, I understand that yoga involves being aware and responsible for my practice to ensure my own personal safety and wellbeing. Please sign here.
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