Yoga Therapy Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

State / Province

Postal / Zip Code

Phone Number*

Date of Birth*

Date

E-mail*

example@example.com

Occupation:

Pronouns:

Emergency Contact:

Primary Physician Contact:

Medical History:

What is the primary condition (s) that you are seeking support for through yoga therapy today?*

Do you experience pain in any part of your body – on occasion, acute or chronic?

Surgeries – include dates of treatment:

Have you been under the care of a licensed health care professional in the past year? For what condition(s)?

Please list medications & supplements you are currently taking:

Have you experienced other health challenges in your life? Please mention any health or medical conditions that you believe may be helpful to your instructor with regard to any precautions that should be taken to ensure your well-being.

Briefly provide a general summary of your daily activities from the time you wake up until you go to sleep IE: Eating, sleeping, exercise, work, activities.

	Time	Description	Variations
Awaken
Breakfast
Morning Activities
Lunch
Mid Day Activities
Dinner
Evening Activities
Bedtime
Snacks/Other

Do you experience heartburn, bloating, or sluggish digestion?

Are you bowel movements: Regular/Irregular?

Do you experience frequent urination, stress incontinence, or other related symptoms?

Do you have 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, drink alcohol, or use marijuana products recreationally? If so, how much per week?

Any current or past problems with addiction or substance abuse?

How would you describe your breathing?

How would you describe your energy levels from the beginning of the day through the evening? IE: wake up rested or tired; mid-day droop; relaxed or wired in evening.

What do you prefer?

Hot TemperaturesCold TemperaturesMoist ClimatesDry Climates

How would you describe your current stress level?

How have your stress levels been in general through your life?

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?

Select those that apply to your experience of sleep:

Awaken feeling restedFalls asleep easilyWakes up frequentlyOther

What is your family and/or community life like?

Do you have friends, family nearby?

Do you live with other people, pets?

What kinds of social activities do you regularly engage in?

Do you have someone close to you to call on if you need assistance or support?

What brings a sense of 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?

What have you found most beneficial from these practices?

What have you found most difficult or challenging?

Have you had any previous yoga injuries? How did they happen?

Do you have any additional comments/questions/concerns you’d like to address?

Waiver and consent:

I understand that the instruction of yoga is provided for the purpose of stress reduction in the form of breath work, relief of muscular tension/weakness through movement, and to support healing the connection between mind, body and spirit, through dialogue and exploration of the teachings of yoga. I further understand that yoga should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, or other qualified medical specialist for mental or physical ailments that I am aware of.

I understand that yoga teachers and yoga therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such. Because the physical practice of some yoga postures is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the teacher/therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.

In consideration of the risk of injury while participating in yoga (the "Activity"), and as consideration for the right to participate in the Activity, I hereby, for myself, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Illuminate Life Yoga LLC, their affiliates, managers, members, agents, attorneys, staff, volunteers, representatives, successors and assigns, for any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.

Signature*

I hereby state that all written records, statements and personal information disclosed by the client is protected and will remain confidential. In the case where it is deemed necessary and of interest to the client to share records with other health-care professionals I will only do so with the expressed permission of the client. It is important to note that while under supervision for the first 150 hours of required practicum client information will be kept confidential when reviewed by said supevision.

Signature*

I would like to receive the Illuminate Life Yoga Newsletter via email to stay current on opportunities to attend workshops, classes and clinics that are being offered in the area and understand that I can opt out anytime.

Signature

Illuminate Life Yoga: Intake Form