Yoga Therapy Intake Form

Name

First Name Last Name

Email

example@example.com

Phone Number

- Area Code Phone Number

Age/DOB

Date

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Referred by

Preferred method of contact to confirm appointment.

Phone Text message Email

What are your current reasons for seeing a yoga therapist? Do you have a goal?

What yoga therapy tools are you most interested in?

Structural Rehabilitation Somatic Inquiry Pranayama Breathing Techniques Meditation Guided Imagery/Relaxation Subtle Body/Tantra (Chanting/Mudras/Chakras)

Do you have prior experience with any of the above mentioned aspects of yoga? If so, what did you like / dislike?

Please list any challenges, illnesses or injuries that you want to address or that may affect your yoga therapy practice. Explain in detail with approximate date of onset.

Have you experienced any significant physical or emotional traumas?

Who else are you currently seeing or your health concerns or general health promotion? How often do you see them?

Please list your current medications, including supplements.

Briefly describe your typical diet. How is your digestion and elimination? do you have daily bowel movements? Would you describe them as normal, loose or constipated?

How would you describe your current level of stress on scale of 1-10 (1 low, 10 high)?

Please describe each area as improving, deteriorating or staying the same and any additional comments.

Home Life

Work Life / Volunteer

Physical Health

Mental / Emotional Health

Spiritual beliefs / practices / affiliations (Is your belief a source of support to you?)

What are your current self care practices, hobbies and interests that are most valuable to you?

Are there areas of discomfort in your body?

Yes No

If yes, please describe location, type / degree of pain and what increases and relieves your pain.

Where do you hold tension in your body?

Is your sleep satisfying?

Yes No

If no, please describe your sleep patterns, medications and total hours of sleep.

How much time can you put aside daily or weekly for yoga therapy?

Bear Foot Yoga, LLC | 262-767-1111 | bearfootyogahealing.com

Yoga Therapy Intake Form

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