Yoga Therapy Intake Form

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Ayurveda, although somewhat recently introduced to the United States, has been practiced in India for over 5000 years. The medical establishment of this country however, does not presently recognize Ayurveda., is available to teach you these health-promoting principles and encourage you to coordinate them with your conventional health care. Ayurveda is a very sacred art and science, and deserves respect and care to maintain its purity. Please consult regularly with your medical doctor, if necessary, and do all things recommended to insure your continued good health. Thank you for trusting me to work with you on your health. I would like to receive a consultation by regarding health education, diet, herbs, cleansing and rejuvenation. I understand that this is an educational session to help me understand my body's natural healing abilities. As such, I take full responsibilities for the choices in health that I make, including the use of any medications prescribed by my primary care physician. I understand that the use of natural methods may cause a cleansing or detoxification effect from medications and/or poor health choices. I am aware that these services are generally not covered by insurance and that all fees will be paid at the time services are rendered by cash or check. I understand that my first consultation is I hereby waive any present or future claims of liability against that may arise out of any treatment sought and received by her. I have read and understood the above. signature date

Yoga Therapy Intake Form Name: email: Phone: Age: Height Weight What are your current reasons for seeing a yoga therapist? Do you have a goal for our time together? List your current & previous health conditions? Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates. How long has your current health issue been going on? Who else are you currently seeing for your health concerns or general health promotion? How often do you see them? Please state the areas of discomfort in your body. Try to describe where they are located and type/degree of discomfort.

Where do you hold tension in your body? What relieves your pain? What increases it? (Consider the movements and range of motion that affect you). Please describe your overall energy level. Does it fluctuate or stay consistent? When are you most energized, least energized? How do you perceive the stress levels in your current life low, moderate, high? Check any of these emotions that you feel on a regular basis. Are there places in your body where these feelings tend to dwell when they come up? Please list. Psychology Worry Irritable Lethargy Anxiety / Fear Anger / Rage Sadness Overwhelm Aggressive Depression Spaced Out Jealousy / Envy Greediness Insomnia Critical / Judgmental Over attachment Self-destructive Intense / Sharp Procrastination Indecisive Tension Controlling Other:

What life challenges are your currently facing? What aspects of your life gives you the most joy and pleasure? If you could change one thing, what would it be? Daily routine and Habits: In percentages, how much of your day is spent with the following: Sitting Driving Standing Desk work Lying Lifting Hours of sleep nightly Time you go to sleep Time awaken Are you usually refreshed on awakening Yes No Type of sleep: Light Medium Heavy Ease in falling asleep: Variable Easy Medium Difficult Ease in waking up: Easy Medium With Difficulty What are your favorite physical movements? Least favorite? Do you have a regular exercise program? Please describe?

How much time (each day/week/month) can you devote to your own personal yoga practice? Please check off items below that apply to you on a chronic or recurrent basis at the present time or within the past year: I. Digestion Heaviness after eating Bloating after eating Sleepy/low energy after eating Belching Nausea Hunger Level: Variable Strong Vomiting Burning indigestion Pain in stomach, intestines or rectum Excessive intestinal gas Gallbladder discomfort Average Low II. Elimination Constipation (<1 BM / day) Blood in stools Diarrhea Mucus in stools Alternate between diarrhea & constipation Unusual color in stool Difficult/painful bowel movements Stools have odor Hemorrhoids Food particles in stool Stool consistency: loose soft hard pellets dry Stool density: float sink scatter Stool color: clay color brown other Number of bowel movements per day Diet: What types of foods are eaten on a regular basis? (at least twice/week) Breakfast: Lunch: Dinner: Snacks: How much water do you drink per day? cups / ounces How many cups of caffeinated beverages per day? Type(s) coffee / tea / soda How many glasses of alcohol per day? Type(s) beer / wine / hard liquor How many cups of non-caffeinated beverages do you drink per day? Type(s) of beverage: milk / juice / herbal tea / other

Please list your current medications vitamins, herbs and supplements. Substance Dosage Taken for how long? Reason

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