Mandorla Yoga Institute
Intake Form: Please fill out for Somatic Therapy, Yoga Therapy and Massage Appointments
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Conditions
Health Questions
Low blood pressure
Characters:
0
/255
Varicose veins
Characters:
0
/255
Diabetes
Characters:
0
/255
Meniere Disease
Characters:
0
/255
Epilepsy
Characters:
0
/255
Vertigo
Characters:
0
/255
Asthma
Characters:
0
/255
Migraines/Headaches
Characters:
0
/255
Gastrointestinal
Characters:
0
/255
Warts
Characters:
0
/255
Blood thinner medication
Characters:
0
/255
Mood Disorder
Characters:
0
/255
Hearing Impairment
Characters:
0
/255
Cancer
Characters:
0
/255
Pacemaker
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Heart Attack
Characters:
0
/255
Past Heart Surgery
Characters:
0
/255
Heart Condition
Characters:
0
/255
Concussion
Characters:
0
/255
Schizophrenia
Characters:
0
/255
Congenital Heart Defect
Characters:
0
/255
High blood pressure
Characters:
0
/255
Depression
Characters:
0
/255
Stroke
Characters:
0
/255
HIV/Aids
Characters:
0
/255
Yoga Interests
Meditation
Characters:
0
/255
Pranayama (breath work)
Characters:
0
/255
Yoga Philosphy
Characters:
0
/255
Asana (postures)
Characters:
0
/255
Eastern Energy System
Characters:
0
/255
Other
Characters:
0
/255
Yoga Goals
Injury Rehabilitation
Characters:
0
/255
Positive Reinforcement
Characters:
0
/255
Address Health Issues
Characters:
0
/255
Strength Training
Characters:
0
/255
Alternative Therapy
Characters:
0
/255
Stress Relief
Characters:
0
/255
Balance
Characters:
0
/255
Flexibility
Characters:
0
/255
Improve Fitness
Characters:
0
/255
Increase Well-being
Characters:
0
/255
Other
Characters:
0
/255
Treatment Goals
Rehabilitation
Characters:
0
/255
Stress Relief
Characters:
0
/255
Support in Healing/Recovery
Characters:
0
/255
Health Advice for Healing
Characters:
0
/255
Improve Lifestyle
Characters:
0
/255
Improve Symptoms
Characters:
0
/255
Improve Well Being
Characters:
0
/255
Pain Relief
Characters:
0
/255
Other
Characters:
0
/255
Trauma Recovery
Somatic Therapy
Yoga Therapy
Massage Therapy
Yoga
Have Practiced Yoga
Characters:
0
/255
Date of Last Yoga Class
Characters:
0
/255
How Often?
Characters:
0
/255
List Expectations
Characters:
0
/255
Anusara
Characters:
0
/255
Ashtanga
Characters:
0
/255
Gentle
Characters:
0
/255
Hatha
Characters:
0
/255
Iyengar
Characters:
0
/255
Kundalini
Characters:
0
/255
Power
Characters:
0
/255
Restorative
Characters:
0
/255
Vinyasa/Flow
Characters:
0
/255
Yin
Characters:
0
/255
Area of Complaint
Neck
Characters:
0
/255
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Upper Back
Characters:
0
/255
Mid Back
Characters:
0
/255
Low Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Left Thigh
Characters:
0
/255
Left Calf
Characters:
0
/255
Right Leg
Characters:
0
/255
Right Thigh
Characters:
0
/255
Right Calf
Characters:
0
/255
Left Gluteal
Characters:
0
/255
Right Gluteal
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Groin
Characters:
0
/255
Right Groin
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Sacrum
Characters:
0
/255
Tailbone (coccyx)
Characters:
0
/255
Headaches
Cluster
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Tension
Characters:
0
/255
Migraines
Characters:
0
/255
Headaches
Characters:
0
/255
Other Headaches
Characters:
0
/255
Neurological
Fatigue
Characters:
0
/255
Carpal Tunnel
Characters:
0
/255
Stabbing
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Peripheral Neuropathy
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Sleeping Disorders
Characters:
0
/255
Stroke
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Numbness
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Dizziness
Characters:
0
/255
Burning
Characters:
0
/255
Chronic Pain Disorder
Characters:
0
/255
Tingling
Characters:
0
/255
Respiratory
Asthma
Characters:
0
/255
Other Respiratory
Characters:
0
/255
Musculoskeletal
Chronic Myofascial Pain Syndrome
Characters:
0
/255
Joint Stiffness / Swelling
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Recti Diastasis
Characters:
0
/255
Spasms / Cramps
Characters:
0
/255
Joint Injury
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Whiplash
Characters:
0
/255
Scoliosis
Characters:
0
/255
Strain/Sprain
Characters:
0
/255
Whiplash
Characters:
0
/255
Bone or Joint Disease
Characters:
0
/255
Arthritis
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Bone or Joint Disease
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
Skin
Allergic Dermatosis
Characters:
0
/255
Infectious Skin Conditions
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Chemical Burn
Characters:
0
/255
Herpes
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Hypersensitive Reactions
Characters:
0
/255
Melanoma
Characters:
0
/255
Melanoma/Carcinoma
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Eczema
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Psoriasis
Characters:
0
/255
Rash
Characters:
0
/255
Rosacea
Characters:
0
/255
Cardiovascular
High Blood Pressure
Characters:
0
/255
Blood Clots
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Chest Pain
Characters:
0
/255
Stroke
Characters:
0
/255
Chest Pain
Characters:
0
/255
Angina
Characters:
0
/255
General Injury Related Questions
Previous sports-related injuries?
Characters:
0
/255
Treatment of previous injury?
Characters:
0
/255
Physical Therapy
Characters:
0
/255
Chiropractic
Characters:
0
/255
OTC medications
Characters:
0
/255
Pain medications or steroids
Characters:
0
/255
Surgery (type/year)
Characters:
0
/255
Complications from that injury?
Characters:
0
/255
Somatic Therapy
Music Preference
Characters:
0
/255
Hearing Impaired
Characters:
0
/255
Sensory Preference
Characters:
0
/255
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.
Characters:
0
/255
Postpartum (check boxes to enter details below)
Any current limitations on your activity?
Characters:
0
/255
Other postpartum concerns
Characters:
0
/255
Vaginal or cesarean birth?
Characters:
0
/255
Currently lactating or nursing?
Characters:
0
/255
Date you gave birth
Characters:
0
/255
Diastasis recti
Characters:
0
/255
Have you seen your midwife/OBGYN since giving birth?
Characters:
0
/255
Name of midwife/OBGYN
Characters:
0
/255
Any birth/postpartum complications or health issues?
Characters:
0
/255
Number of weeks postpartum
Characters:
0
/255
Massage Goals
Increase Well-Being
Characters:
0
/255
Injury Rehabilitation
Characters:
0
/255
Address Health Issues
Characters:
0
/255
Pain Relief
Characters:
0
/255
Positive Reinforcement
Characters:
0
/255
Flexibility
Characters:
0
/255
Stress Relief
Characters:
0
/255
Improve Symptoms
Characters:
0
/255
Date of Last Massage
Characters:
0
/255
Massage Frequency
Characters:
0
/255
Light Pressure Preferred
Characters:
0
/255
Medium Pressure Preferred
Characters:
0
/255
Other
Characters:
0
/255
Deep Pressure Preferred
Characters:
0
/255
Which best describes what you are experiencing
Pain
Characters:
0
/255
Mild
Characters:
0
/255
Getting Worse
Characters:
0
/255
Ache
Characters:
0
/255
Moderate
Characters:
0
/255
Staying the Same
Characters:
0
/255
Tension
Characters:
0
/255
Disabling
Characters:
0
/255
Getting Better
Characters:
0
/255
Discomfort
Characters:
0
/255
Constant
Characters:
0
/255
Imbalance
Characters:
0
/255
Intermittent
Characters:
0
/255
Increases with Activity
Characters:
0
/255
Decreases with Activity
Characters:
0
/255
No Change
Characters:
0
/255
Other
Characters:
0
/255
Current Complaint
Pain Severity: 1-10
Characters:
0
/255
Date of Injury?
Characters:
0
/255
Prescription pain meds Did it help?
Characters:
0
/255
Steroids (oral) Did it help?
Characters:
0
/255
Steroids (injection) Did it help?
Characters:
0
/255
Heat Did it help?
Characters:
0
/255
Cold Did it help?
Characters:
0
/255
Immobilization Did it help?
Characters:
0
/255
Other creams, gels or unguents
Characters:
0
/255
Other therapies
Characters:
0
/255
Allergy
Latex
Characters:
0
/255
Sensitive to scents/essential oils
Characters:
0
/255
Coconut Oil
Characters:
0
/255
Other Allergies
Characters:
0
/255
Emotion / Mood / Trauma History
Despair
Characters:
0
/255
PTSD
Characters:
0
/255
Fear
Characters:
0
/255
Rate the stress in your life (1-10)
Characters:
0
/255
Grief
Characters:
0
/255
Sadness
Characters:
0
/255
Mental Abuse History
Characters:
0
/255
Anger
Characters:
0
/255
Stress Response and Coping Strategies
Characters:
0
/255
Negative Self-Talk
Characters:
0
/255
Anxiety
Characters:
0
/255
Other Emotions
Characters:
0
/255
Confusion
Characters:
0
/255
Overall mood and energy level
Characters:
0
/255
Depression
Characters:
0
/255
Physical Abuse History
Characters:
0
/255
Submit Form
×