Kerrie Cason Hawkes Yoga
Yoga Therapy Intake Form
Client's Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Weight
Gender
Male/Female/Non-Binary/Prefer Not To Say
Occupation
Are you currently or potentially pregnant?
Yes
No
Please describe the health problems you are having now
Have you practiced yoga before?
Yes
No
How often?
More than 3 classes per week
1-2 classes per week
On occasion
Have you practiced meditation before?
Yes
No
How often?
Daily
Sometimes
What have you found beneficial in these practices?
What have you found most difficult or challenging in these practices?
What are your hopes and goals in working together?
Reason for seeking Yoga Therapy
Goals for Yoga Therapy
Preferred Session Format
In-person
Virtual
Either
Other
Preferred Time for Sessions
How did you hear about us?
Website
Social Media
Referral
Other
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Symptom Evaluation
What is the location of your discomfort? Please describe your symptom(s).
When did your symptom(s) begin?
Did your symptom(s) begin suddenly or gradually?
Is the symptom(s) constant or intermittent?
How long does the symptom(s) last?
How often do you experience this difficulty?
What makes your symptom(s) worse? Choose as many as are relevant.
Stress
Yoga Practice
Sitting
Driving
Bending
Twisting
Certain Movements
Movements in General
Resting
Other
If other please describe
What makes your symptom(s) better? Choose as many as are relevant.
Stress
Yoga Practice
Sitting
Driving
Bending
Twisting
Certain Movements
Movements in General
Resting
Other
If other please describe
Have the symptom(s) changed since they began?
Do your symptom(s) impact your quality of life?
Do your symptom(s) occur at a specific time of day?
Do your symptom(s) have an impact on your participation in your daily activities; I.e. work, leisure, exercise, etc.?
Are there daily activities that you are not able to do because of your symptoms that you would like to be able to resume?
What directions of movement result in the symptom(s); i.e. spinal flexion, extension, twists, lateral bending or movement of arms/legs, etc.?
Do your symptom(s) interfere with your sleep?
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Pain Evaluation
Based on the scale above rate your pain.
How would you describe your pain? (dull, sharp, piercing, electric, constant, intermittent, located in the same place, pain moves around, etc)
Do you have inflammation?
Yes
No
If yes what part of your body has inflammation?
How would you describe your symptoms (red, swollen, warm, hot, tight, etc.)
What body positions help alleviate the pain and/or inflammation?
What is the most comfortable position?
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Current Care
Self Care - How have you attempted to manage this problem or your symptom(s)?
Professional Care - Who have you consulted for this problem? What have they suggested?
Professional Care - If you have a diagnosis what is it?
Pharmaceutical Care - Do you currently take medication for this or other issues? If so what?
Have you had any recent surgery or procedures?
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Client Perspective
What do you think caused/is causing the problem?
What do you think will help you? How do you hope yoga will help the problem?
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Lifestyle Questions
How is your appetite?
Weak
Intermittent
Strong
Burning
Steady
When are you hungry?
When do you eat?
How do you feel after eating? Choose as many as are relevant.
Bloated
Heavy
Gassy
Heartburn
Painful
Tired
Energized
How is your elimination? Choose as many as are relevant.
Normal
Loose
Pellets
Diarrhea
Constipated
Oderous
Painful
Undigested
How is your urination? Choose as many as are relevant.
Frequent Day
Frequent Night
Infrequent
Incontinent
Painful
What are your sleep patterns? Choose as many as are relevant.
Early to bed
Early to rise
Late to bed (after 10pm)
Late rise
Under 8 hours
Over 8 hours
Restless sleep
Deep sleep
Sleep apnea
Insomnia
Disturbing dreams
Do you experience any skin problems? Choose as many as are relevant.
Acne
Dryness
Eczema
Psoriasis
Hives
Rashes
Other
If other please describe
What are your average body sensations? Choose as many as are relevant.
Hot face, hands, feet
Cold face, hands, feet
Chest tightness
Stomach tightness
Heart palpitations
Other
If other please describe
How many hours a week do you work?
Under 20 hours
20-40 hours
Over 40 hours
Other
If other please describe
How many hours a week do you exercise and what do you do?
Do you sweat?
Profusely
Only during exercise
Almost never
What is your stress level from 1-10 (1 being no stress, 10 being overwhelming)
When dealing with stress what is your normal reaction?
Anger
Fear
Inertia
Thrive on stress but then can burn out
Do you get headaches?
Frequently
Occasionally
Almost never
When you get sick is it generally?
Head cold
Chest cold
Digestive
If you are assigned female at birth are you experiencing any of the following menopausal symptoms? Choose as many as are relevant.
Hot flashes
Irritability
Night sweats
Trouble focusing (Brain Fog)
Irregular periods
No longer having a period
Depression
Weight gain
Joint and muscle aches
Anxiety
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Tell Me About Your Diet
How much water do you drink per day?
Do you drink coffee?
Yes
No
Do you eat processed sugar?
Daily
A few times a week
Occasionally
Never
Are you open to dietary changes if they may help to alleviate your symptom(s)?
Yes
No
Maybe
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Client General Health History
Have you had any major illnesses or trauma? If so where and when?
If so what and when?
What was the treatment?
If so what and when?
Do you have any family history of this kind of condition or symptom(s)?
Do you have any family history of other conditions or symptom(s)?
Is there anything else you'd like to tell me before our sessions?
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