Yoga Therapy Intake Form

Yoga Therapy Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation (or previous occupation if retired)
Emergency Contact (name and #)
Yoga Practice Experience
Have your practiced yoga before?

YesNo
If yes, last date of practice?
How often do you practice yoga?

DailyWeeklyMonthly
Styles of yoga practiced (circle all that apply):

HathaVinyasaRestorativeBikramPowerIyengarKundaliniGentleHot YogaOther
Style(s) most practiced or preferred:
Goals
What goals to you wish to accomplish through yoga therapy (circle all that apply)?

Strength TrainingFlexibilityBalanceImprove Overall FitnessWeight ManagementStress ReductionPain ReductionProcess Loss /Grief/DepressionIncrease Personal Well-being
Lifestyle Habits and Wellness Behaviors

Fitness Behaviors
Fitness Behaviors

SedentarySomewhat ActiveActiveExtremely Active
Describe your current workout/exercise:
What is your workout frequency and duration? (i.e. daily/1hr.)
How would you rate your overall level of stress on a scale of 1 to 5 (1 is lowest and 5 is highest)?
Complementary Therapies:
Have you had any holistic alternative therapy?

YesNo
If yes, please check which type(s):

AcupunctureAlpha-bioticAlignmentsBodyWork (Deep Tissue massage,Energy/Reiki, Maya Abdominal massage)Chiropractic AdjustmentsCranial Sacral TherapyHerbal/Naturopath supplements therapyHydro-colonicsOther
Reason and what was the outcome of therapy?
Sleep Behaviors:
When do you typically go to bed and typically wake up?
Do you find it difficult to sleep? Do you need any type of sleep aid?
How do you sleep? On back, side, stomach?
Nutritional Behaviors
On an average day what do you eat? Describe:
What are your eating patterns? (Check all that apply)

RawVeganVegetarianPescatarianCarnivoreOrganicWhole Foods (as opposed to processed)
Fast Food(s): Describe what types and how often? Is this a lifestyle pattern?
Stress induced eating: Describe triggers (emotions attached to behavior/s)
Have you ever been on a specific type of diet for health purpose? Describe:
Habit Forming Behaviors
Do you smoke?

YesNo
If yes, how many packs per day?
Do you consider yourself a social drinker or drink excessively? Describe:
Do you use recreational drugs?

YesNo
If yes, what type of recreational drugs and how often? Describe: (Answers will be kept strictly confidential.)
Do you use pain medication?

YesNo
If yes, what was the reason for the prescription? What type of painmedication? How often?
Any Addictions?

YesNo
If yes, what kind(s) of substance abuse”
Are you in recovery?

YesNo
If yes, how long?
Spiritual Awareness
Do you have a specific faith-based belief? What is it?
How do you express your belief?
How important is it to nurture and care for your spiritual well-being? On a scale from 1 to 5, rate the level of importance it is to develop and care for your spiritual well-being ( 1= lowest, 5 = highest)
Do you desire a deeper spiritual relationship?

YesNo
If yes, describe:
Physical and Mental Health History
Please review the following list and check condition(s) that have affected your health either recently or in the past:

broken/dislocated bonesarthritis,bursitismuscle strain/spraindisc problemsscoliosisback problemsosteoporosisosteopeniaDiabetes 1Diabetes 2high/low bloodpressureinsomniaanxietydepressiondiagnosed mental health disorderasthmashortness of breathnumbness/tingling anywherecancer (describe below in comments)pregnancy (how many - describe below)female issues (describe below)surgery(ies) (describe below)seizurestraumatic brain injury or concussion(s)strokes or TIA'sheart conditionchest painauto immune disorderfibromyalgiaother conditions
Emotional Trauma
Have you ever been the victim of abuse?

YesNo
Check type(s) of abuse:

PhysicalMental/emotionalSexualAbandonment/Neglect
Did you receive counseling/therapy?
Do you have any trauma or crisis that entailed loss/grief?

YesNo
Describe:
Did you receive counseling therapy? Describe:
Are these issues you wish to address through holistic psycho-therapy?

YesNoMaybe
Explain:
Are you currently on any type of medication? If yes, please list names and reason for medication.
Are you currently seeing a healthcare professional? If yes, please list name and reason:
Please list any further information that you believe would be beneficial to your Holistic and Mind Body Therapist to better assist you in meeting your health and wellness goals.
Thank you for taking time to fill this form.

Lisa Lines Gregor

Mind Body Therapist
CONSENT TO TREAT THROUGH ROCKY MOUNTAIN MIND BODY THERAPY
I understand that Yoga Therapy includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling injury, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the instructor. I understand that my Yoga Therapist may assist me in yoga postures.

Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I may have now or hereafter may have against LISA LINES GREGOR.

I will pay for yoga therapy lessons upfront. I will provide LISA LINES GREGOR a 24-hour notice if I need to cancel. If I do not provide a 24-hour notice, I will still be charged for that lesson.
Client Signature: (by typing your full name below, you consent to Yoga Therapy treatment)
Date of Signature:
Should be Empty:

Yoga Therapy Intake Form

Yoga Practice Experience

Goals

Lifestyle Habits and Wellness Behaviors

Complementary Therapies:

Sleep Behaviors:

Nutritional Behaviors

Habit Forming Behaviors

Spiritual Awareness

Physical and Mental Health History

Emotional Trauma

CONSENT TO TREAT THROUGH ROCKY MOUNTAIN MIND BODY THERAPY