Dear Yoga Therapy Case Study Applicant,
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- Scot Waters
- 6 years ago
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1 Dear Yoga Therapy Case Study Applicant, Many thanks for your interest in our program. We will do our best to secure a spot for you in our on- going free Saturday Clinic. Our only request is your commitment to at least four (4) sessions so that our Clinical Therapy candidates may monitor and learn from your progress. Each session will provide you with a comprehensive Yoga Therapy Protocol along with picture tutorial taken during your session so that you might practice at home. To apply, please fill out the attached Clinical Case Study Application, read and sign The attached Disclosure and Photo Release forms, and return to my attention at: AUM Home Shala Attn: Melinda Atkins, Director 3104 Florida Ave. Coconut Grove, FL Should you have any questions, feel free to contact us via (info@aumhomeshala.org) or phone ( ) Namaste, Melinda Atkins Director
2 Clinical Case Study Application Confidential Health Background AUM Home Shala Yoga Therapy Personal Information Name: Birthday: Daytime Phone: ( ) Evening Phone: ( ) Address: Occupation: Address: City: State: Zip: Emergency Contact: Phone: ( ) The following confidential information will be used to plan safe and effective yoga therapy sessions. Please answer the questions to the best of your knowledge. Reason for your visit What is your primary issue? How often do you experience your symptoms? Constantly (76-100% of the time) Frequently (50-75%) Occasionally (26-50%) Intermittently (up to 25%) When did you first notice it? Do you know what brought it on? What activities provide relief? What makes it worse? How are your symptoms changing with time? (circle one) Getting Worse Staying the same Getting better Have you tried ay other therapies or treatments? (Y/N) If yes, please describe: Describe your sleep recently: What do you hope to accomplish? Body Awareness Muscle Strengthening Muscle Stretching and Flexibility Improve Other Body Systems: Stabilization of Joints Diet and Lifestyle Pain Reduction Digestion and Elimination Overall Posture Improvement Specific Yoga Postures or Practices Improve Breathing Improve Energy Level Improve Sleep Breath Awareness Overall Stress Reduction Less Trouble Handling Emotions Less Reactive/Upsetting Less Anxiety or Depression More Satisfying Personal Relationships Finding Greater Fulfillment at Work Greater Sense of Self- esteem Other goals: How much time per day can you devote to doing yoga or healing work?
3 Health History Are you currently under a physician s care for an acute or chronic issue? (Y/N) If yes, please explain Health Care Provider: Date of last Physical Exam: What do you do for relaxation/exercise? Do you exercise regularly and/or participate in any sport? (Y/N) If yes, which sport? Have you recently suffered an injury? (Y/N) If yes, please explain Are you uncomfortable with any of the following areas: Gluteal Region (Y/N) Pectoral Region (Y/N) Face/Scalp (Y/N) Feet (Y/N) Please list any medications (vitamins, herbs or pharmaceutical) you are currently taking or at regular intervals? Please list any injuries/accidents/illnesses or surgeries still affecting you and how you have been caring for them: Do you experience stress in your work, family or other aspects of your life? (Circle the one that best describes) And how you believe it affects your health: Muscle tension Anxiety Insomnia Irritability Digestive Disturbances Other:
4 Circle the face or faces that best describes how you are feeling Using the symbols below, please identify the areas of concern on the chart below: /// (sharp pain) xxx (burning, radiating pain) ~~~~ (numbness) 000 (dull ache)
5 Health History Please indicate any Present (P), Past (X), or Reoccurring (C) conditions: ADD/ADHD Allergies Alzheimer s disease Anxiety disorder Arthritis Athletes foot Asthma Blood Clot/ Deep Vein Thrombosis/ Phlebitis/ Embolism Broken or fractured bones Bursitis Cancer - - Location: - - Treatment: - - In Remission? Y/N Carpal Tunnel Syndrome Cerebral Palsy Chronic Fatigue Syndrome Contagious condition Crohn s disease Depression Diabetes Type I Type II Diverticulitis Eczema Epilepsy Epstein Barr Fertility Concerns Fibromyalgia General Fatigue Gout Headaches - - Type: Frequency: Hearing Impairment Heart Condition Herpes/ Shingles High/ Low Blood Pressure High/ Low Cholesterol HIV/AIDS Lupus Lymph edema Metal implants / artificial joints Mononucleosis Multiple Sclerosis what stage? Muscular Dystrophy Numbness/ Tingling Osteoporosis/Osteopenia Osteoarthritis Pain Rheumatoid Arthritis - - Location: - - Muscular or Joint: - - Chronic? Y/N Paralysis Parkinson s disease Pregnancy Psoriasis Rash Sciatica Scoliosis Seizure Sleeping problems Spasms/ Cramping Strain/ Sprain Stroke Tendonitis Thyroid issues TMJ/ Jaw Pain Tumor - - Location: - - Malignant or Benign? Varicose Veins Vertigo, dizziness or loss of balance Other:
6 Release and Consent to Photograph For use to promote AUM Home Shala Teacher Training and Yoga Therapy Programs (PLEASE PRINT) Subject sname: Address: Phone Numbers: (H) (Cell) AUM Home Shala established its Yoga Teachers Training Program in I understand that AUM home routinely promotes the educational and health benefits of participating in the activities of on going Yoga classes and training programs. I hereby consent to being the subject of photographs taken to promote AUM Home Shala Educational Yoga programs and hereby release AUM home from any and all claims for damages for libel, slander, invasion of privacy or any other claim based upon the use of my image and likeness as stated above. Date Date Signature Melinda Atkins, M.ED., E- RYT500C Director
7 AUM home Shala Professional Disclosure Form and General Release We are delighted to have you as a Yoga student. The following information will help you get the most out of your Yoga classes and clarify the role of a Yoga teacher. Please read and sign below. 1. I am a Yoga Teacher at AUM home Shala and have completed a thorough professional training in Yoga instruction. I have a Yoga Certification and am registered with the Yoga Alliance. Yoga is much more than physical exercise; it is a transformational practice that integrates body, mind and spirit. Yoga is a way of encountering and releasing physical, mental, and emotional tensions to arrive at deeper levels of relaxation and awareness. 2. All exercise programs involve a risk of injury. By choosing to participate in my Yoga classes, or any other classes at AUM home Shala, you voluntarily assume a certain risk of injury. The following guidelines will help you reduce your risk of injury: Listen to and follow Yoga Teacher s instructions carefully. Breathe smoothly and continuously as you move and stretch. Do not hold your breath or strain to attain any position. Work gently, respecting your body s abilities and limits. Don t perform postures or movements that are painful. Ask if you are unsure how to perform a certain movement. Menstruating women should not practice inverted postures. Pregnant women must consult their health care provider before enrolling in class. 3. It is always advisable to consult your physician before embarking on any exercise program. Please complete the Student Health Questionnaire Form and inform the teacher of any health conditions that could be affected by your practice of Yoga. If you are unsure about a condition, please speak to your teacher. 4. Awareness is fundamental to the practice of Yoga. It is your responsibility as a student to monitor each activity and determine whether it is appropriate for you to participate. Though I am your teacher, you remain primarily responsible for your safety and well- being. The undersigned assumes all risk of damage or injury that may occur as a student in AUM Home Shala Yoga classes, both while attending classes and following instruction at home. In consideration of being accepted as a Yoga student the undersigned releases and discharges Melinda Atkins, AUM home Shala from any and all claims, demands, actions of any nature, whether present or future, anticipated or unanticipated, known or unknown, that result from the undersigned s participation in Yoga classes or practice of Yoga outside of class. I have read, understand, and agree to the content of the Professional Disclosure Form and General Release. Student s Name (please print) Student Contact # Student s Name (please sign) Emergency Contact Name & Phone # Date E- mail address
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Eastern Shore MediCann Clinic, LLC
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CONSULTATION ADMITTANCE FORM
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PATIENT INFORMATION FORM
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New Adult Intake Form
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ADIO CHIROPRACTIC HEALTH PROFILE
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Welcome to Lone Lake Physical Therapy!
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CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
Vibrant Life Healthcare 6105 Patricia Bay Highway Victoria, BC, V8Y 1T4
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NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone: