Intake Form

Intake Form

All information given in this questionnaire is strictly confidential.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
Your physician
Physician’s contact
Occupation/ Employer
CONCERN(S)
What is the primary concern or goal for today?
Have you had this in the past?
When did it begin? Please describe.
If painful, how bad is the pain/discomfort on a scale of 1-10 with 10 being worse.

1

2

3

4

5

6

7

8

9

10

1 is Best, 10 is Worst
Does anything make it better? Does anything make it worse?
Please list other current concern(s):Complaint/ How long/Cause (if known)
Do you have any specific body discomfort? If yes, please describe and does it radiate or travel anywhere?
Are you seeing healthcare or other service providers for this issue/condition? (acupuncturist, physical therapist, massage practitioner)? (Yes/No) If so, what is the diagnosis and what treatments, if any, have your tried?
What else, if anything, are you doing for this?
Have you made any observations about your body, energy, mental or emotional life, or beliefs in relation to this concern you would like to share?
In what way(s) do you think yoga movement therapy can be of help to you?
LIFESTYLE
How many hours do you work each week, and do you like your work?
Do you perform any repetitive movement in your work, sport, yoga practice, recreation, home care, or other activities?
Does your work stress or exhaust you? (Yes/No) Why:
Do you generally get enough sleep? (Yes/No) Please describe:
Living Status:

SingleMarriedPartnerDivorcedWidowed
Children
Are you currently or have you recently gone through an unusually stressful life change or event? (divorce, death in family, etc.)
What kind of diet do you eat?

Typical AmericanVegetarianVegan, PaleoOther
Do you smoke cigarettes, cigars, marijuana? (Yes/No) If yes, list
Do you drink alcohol? (Yes/No) If yes, how many drinks per week?
Do you use recreational drugs? (Yes/No) If yes, what and how often?
What do you do to exercise and how often? (Ex. Walk 30 min/5 days a wk.)
What current or past sport, movement, dance, performance or art experience do you have?
What is your experience with yoga, meditation or similar eastern or wholistic practices?
What are your biggest stressors?
Do you sit for long hours at a workstation, computer, watching TV and/or driving?
What do you do for fun and/or to relax?
MEDICATIONS, ALLERGIES & SUPPLEMENTS
Please list allergies to medicines, foods and environmental factors:
Please list prescription and dose of over-the-counter medications:
Please list vitamins, minerals, herbal preparations, tonics, supplements, flower essences, cell salts, homeopathic remedies, or the like, taken regularly:
HISTORY
List major illnesses and hospitalizations (operations, injuries/accidents and their dates):
Have you ever been diagnosed with any illness or health condition? If so, what year?
Please list and briefly describe any conditions, medical or otherwise, that may prohibit or limit your practice of yoga stretches, movements, breathing, meditation, introspection, or relaxation:
Is there anything else you feel would be helpful for me to know?
Yoga Therapist Practicum Experience

The yoga therapy session will be carried out by a student in the advanced level of the Spanda® Yoga Movement Therapist training. The student working with you is not certified by the International Association of Yoga Therapists, the standard of professional yoga therapy worldwide, and is not yet qualified to offer yoga therapy outside of this practicum experience. However, the student is closely supervised by a yoga therapist who is certified by IAYT. Yoga therapist training, while including some teaching methods, is not a yoga teacher training but a professional level therapist training using the techniques and methods of yoga science and philosophy. Your case may be discussed during supervision with faculty supervisors while your right to privacy and anonymity will be ensured.
(Name/ Date)
If under 21, legal guardian’s name:
Should be Empty:

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Intake Form

CONCERN(S)

LIFESTYLE

MEDICATIONS, ALLERGIES & SUPPLEMENTS

HISTORY