Mandorla Yoga Institute
Intake Form: Please fill out for Somatic Therapy, Yoga Therapy and Massage Appointments
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Conditions
Health Questions
Low blood pressure
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Varicose veins
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Diabetes
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Meniere Disease
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Epilepsy
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Vertigo
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Asthma
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Migraines/Headaches
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Gastrointestinal
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Warts
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Blood thinner medication
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Mood Disorder
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Hearing Impairment
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Cancer
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Heart Condition
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Concussion
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Schizophrenia
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Congenital Heart Defect
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High blood pressure
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Depression
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Stroke
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HIV/Aids
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Yoga Interests
Meditation
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Pranayama (breath work)
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Yoga Philosphy
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Asana (postures)
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Eastern Energy System
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Other
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Yoga Goals
Injury Rehabilitation
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Positive Reinforcement
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Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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Flexibility
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Improve Fitness
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Increase Well-being
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Other
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Treatment Goals
Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Other
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Trauma Recovery
Somatic Therapy
Yoga Therapy
Massage Therapy
Yoga
Have Practiced Yoga
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Date of Last Yoga Class
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How Often?
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List Expectations
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Anusara
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Ashtanga
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Gentle
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Hatha
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Iyengar
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Kundalini
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Power
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Restorative
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Vinyasa/Flow
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Yin
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Other Headaches
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Neurological
Fatigue
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Carpal Tunnel
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Stabbing
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Fibromyalgia
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Peripheral Neuropathy
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Sciatic Pain
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Sleeping Disorders
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Stroke
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Herniated Disc
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Numbness
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Loss of Sensation
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Dizziness
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Burning
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Chronic Pain Disorder
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Tingling
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Respiratory
Asthma
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Other Respiratory
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Musculoskeletal
Chronic Myofascial Pain Syndrome
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Recti Diastasis
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Spasms / Cramps
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Joint Injury
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Osteoarthritis
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Whiplash
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Scoliosis
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Strain/Sprain
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Whiplash
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Bone or Joint Disease
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Arthritis
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Osteoporosis
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Bone or Joint Disease
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Jaw Pain (TMJD)
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Other Musculoskeletal
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Skin
Allergic Dermatosis
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Infectious Skin Conditions
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Athlete's Foot
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Chemical Burn
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Herpes
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Bruise Easily
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Hypersensitive Reactions
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Melanoma
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Melanoma/Carcinoma
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Skin Conditions
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Plantar's Wart
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Eczema
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Skin Irritations
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Psoriasis
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Rash
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Rosacea
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Cardiovascular
High Blood Pressure
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Blood Clots
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Low Blood Pressure
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Chest Pain
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Stroke
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Chest Pain
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Angina
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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Somatic Therapy
Music Preference
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Hearing Impaired
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Sensory Preference
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Please share something that is a positive resource for you. This could be the warmth of sunlight, the smell of a comforting food, a memory of a person, place or animal that helps you to feel more regulated or connected with your body.
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Postpartum (check boxes to enter details below)
Any current limitations on your activity?
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Other postpartum concerns
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Vaginal or cesarean birth?
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Currently lactating or nursing?
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Date you gave birth
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Diastasis recti
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Have you seen your midwife/OBGYN since giving birth?
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Name of midwife/OBGYN
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Any birth/postpartum complications or health issues?
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Number of weeks postpartum
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Massage Goals
Increase Well-Being
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Injury Rehabilitation
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Address Health Issues
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Pain Relief
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Positive Reinforcement
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Flexibility
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Stress Relief
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Improve Symptoms
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Allergy
Latex
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Sensitive to scents/essential oils
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Coconut Oil
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Other Allergies
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Emotion / Mood / Trauma History
Despair
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Anger
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Stress Response and Coping Strategies
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Negative Self-Talk
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Anxiety
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Other Emotions
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Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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