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.
Full Name
*
First Name
Last Name
Email
Phone Number
*
-
Area Code
Phone Number
Check the conditions that apply to you or to any members of your immediate family (please specify later details in fields below if applicable):
*
Asthma
Cancer
Cardiac disease
Diabetes
High / low blood pressure
Psychiatric disorder
Epilepsy
Eating disorder
Depression
Anxiety
None of the above
Other
Date of Birth
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Month
-
Day
Year
Date
Are you currently taking any medication?
*
Yes
No
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.?
1 month+
6 months+
1 year+
other
Are you currently seeing any other health practitioners?
Chiropractor
Physiotherapist
Acupuncturist
Massage Therapist
Ayurvedic Specialist
Naturopath
Yoga Therapist
Kinesiologist
GP
Psychologist
Pyschiatrist
Multiple 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?
*
Not great
Okay
Great
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?
Poor
Okay
Great
Amazing!!!
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
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
Occupation?
Pick what your daily movement most aligns with...
Primarily standing/walking around/active
Primarily sitting (at a desk)
Primarily driving
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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