New client intake paperwork Name * First Name Last Name Preferred pronouns Email * Address * Phone Date of birth * Emergency contact info * Please include name and phone number Primary physician name and phone * Occupation * Do you have or have you had: * High blood pressure Glaucoma Osteoporosis Seizures Diabetes Rheumatoid arthritis Anemia Heart problems Asthma Other breathing problems Dizziness, vertigo or loss of balance Unexplained falls or fractures Hearing difficulty Hernia/rupture Unstable/ "trick" joint(s) Hearing difficulty Metal implants/artificial joints Bladder or bowel control problems Pinched nerves or disc problems Cancer Broken bones Allergies Blood thinners Neurological diseases Headaches Vision difficulties Chest pain Shortness of breath Night sweats Joint swelling Traumatic auto accidents Major surgeries Other chronic conditions: Hysterectomy Menopausal challenges Caesarean delivery Early termination of menses Do any of the following currently apply? * Back problems Hernia Joint problems Epilepsy Arthritis Low blood pressure Hypoglycemia Chronic fatigue Anxiety/depression What is your predominant reason for seeking yoga therapy at this time? * Please list any recent surgeries * Medications and supplements that you are currently taking * Have you experienced other health problems or challenges in your life? * Do you experience pain in any part of your body –on occasion, acute or chronic? * Tell me a little about your lifestyle? Diet? Exercise program? Do you smoke or drink? * How is your breathing? * How would you describe your energy levels? * Would you describe your overall energy as stable or quite variable? * How is your stress level? * 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? * Do you awaken from sleep feeling rested? Do you fall asleep easily? * How do you have fun in 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 and is your practice regular? * 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? * What do you hope to get out of Yoga practice? What is your main goal for Yoga practice? * Do you have any other comments/concerns? * Thank you!
