New Client-Yoga Therapy Information Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
If someone referred you to us, whom specifically may we thank?
What are your primary reasons for coming to Yoga Therapy?
How long have you had this condition?
Have you experienced this before? YES NO
What seemed to be the initial cause?
What seems to make it better?
What seems to make it worse?
Does it bother your: Sleep Work Other:
PERSONAL LIFESTYLE HABITS (how much, how many, or how often).
MAJOR HOSPITALIZATIONS: If you have ever been hospitalized for any serious medical illness or operation, write the most recent one below: (do not include normal pregnancies).
How would you describe your overall health?
Date of last physical examination:
Name & Address of physician:
Phone number of physician:
*Do I have the permission to contact your physician to further serve you with your health and wellness?
*If you answered yes to the above question please fill out the authorization form giving us permission to contact your doctor.
*Does your doctor/healthcare practitioner know that you are participating in Yoga Therapy?
*Is there anything that surfaced during a recent medical test, lab work, or doctor’s visit that you would like to report?
If yes please explain:
Is there now or has there historically been any illness or physical challenges which may impact your Yoga practice? Please share below:
Do you ever experience your energy level as any of the following?
Please check all that apply:
Does your energy fluctuate or is it constant?
When is your energy at its highest?
When is your energy at its lowest?
What is your energy like when you first awaken?
On average how long do you sleep at night?
*Do you struggle with insomnia or staying asleep? Yes No
Are you having difficulty with any of the following? Please check all that apply.
Explain if desired:
On a scale from 1-10 with 1 being low and 10 being high, how stressful is your:
Yoga Therapy – INFORMED CONSENT
- I hereby consent to engage in Yoga Therapy. I understand that Yoga therapeutic methods are based on principles of Yoga, scientific data, and the experience of Yoga teachers, and they are not, as yet, considered standard treatments in mainstream medicine or physical therapy. I understand and am informed that I should consult with my physician and obtain his or her consent prior to beginning therapy. I also understand and am informed that I have been advised to consult a physician if I have not done so.
- I understand and am informed that, during the Yoga Therapy sessions, I will complete the activities designed for my condition. Should any symptoms, pain, discomfort, or other concerns occur or change at this point, I will immediately inform the Yoga Therapist, as necessary adjustments in my therapy may be appropriate. I understand that touching or positioning of my body may be necessary to ensure that I am using the appropriate procedure, and I expressly consent to such physical contact. If I do not wish to be touched, I will not initial the consent here to notify the Yoga Therapist, so that a joint decision can be made about where it is appropriate to continue the practice with that limitation.
- I understand and am informed that there are inherent risks associated with Yoga Therapy, yoga training, strength training, and other forms of physical activity. Such inherent risks include, but are not limited to, acute muscle and/or joint pain, pulled muscles, brief changes in blood pressure, light headedness and/or dizziness which could cause slip and fall, delayed onset muscle soreness, more chronic conditions such as tendonitis, and other discomforts.
- I understand and am informed that my Yoga Therapist is not a licensed physician and that the Yoga Therapy provided is complementary to licensed healing arts. I also understand that my therapist has completed and holds a Master’s Degree in Yoga Therapy.
- To promote the safety and benefit of Yoga Therapy, I shall fully disclose my personal health history, any medications I am taking, and any symptoms I may be experiencing during the Yoga Therapy session(s). Such symptoms would include back/neck/joint pain, irregular heart rhythm, tightness, or pressure in my chest, unusual shortness of breath, light headedness, dizziness and any other symptoms that are of concern.
- I understand and agree to pay full fee for appointments cancelled with less than 24 hour’s notice.*
- I have carefully read and understand all the foregoing and so am fully aware of what I am signing. I have felt free to ask any questions.
* Prices subject to change