Yoga Therapy - Initial Intake Form, v5

Do you experience pain in any part of your body? If so, is the frequency on occasion, acute, or chronic?

Have you been under the care of a licensed health care professional in the past year? For what condition(s)?

Have you experienced other health challenges in your life, and/or would you care to elaborate about any of the above answers?

Do you have symptoms related to menstruation?

Are you pregnant?

Are you trying to become pregnant?

Are you experiencing perimenopause / menopause symptoms?

Are you on hormones (birth control, MHT, etc)?

Have you had a hysterectomy or oophorectomy?

Any other condition you'd like to share?

Please explain or elaborate upon any other health or medical conditions that you believe may be helpful to your yoga therapist with regard to any precautions that should be taken to ensure your optimal well-being.

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What time of day do you eat breakfast?

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What are the most common foods you consume for breakfast?

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What time of day do you eat lunch?

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What are the most common foods you consume for lunch?

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What time of day do you eat dinner?

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What are the most common foods you consume for dinner?

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What time(s) of day do you snack?

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What are the most common foods you consume as snacks?

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Do you experience heartburn, bloating, or sluggish digestion?

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Do you experience frequent urination, stress incontinence, or other related symptoms?

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Are your bowel movements regular or irregular?

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How much water do you drink per day?

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How many cups of caffeinated beverages do you drink per day? What type(s) of beverage: coffee/tea/soda/etc?

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How many cups of non-caffeinated beverages do you drink per day (not including water)? What type(s) of beverage: herbal tea/milk/juice/other?

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Do you smoke, drink alcohol, or use cannabis or psychedelics? If so, how often?

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Generally summarize your daily routine from the time you wake up until you go to sleep – include waking time, eating, exercise, work, activities, naps/bedtime, child care, etc

Are there any additional activities that may not be included in the above schedule (e.g., exercise, meditation, spiritual practices, etc)?

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Any other comments about your daily routines you'd like to share?

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steady

erratic

deep

shallow

chest

belly

combo chest & belly

involuntary breath holds accompanied by big sighs

frequent breathlessness

frequent yawning

frequent sniffing

mouth breathing

nose breathing

combo nose & mouth breathing

I'm not sure

How would you describe your current stress level?

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How have your stress levels been in general throughout your life?

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What types of situations cause stress or bring it on for you?

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What are some of the ways you've found most effective for stress relief?

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Throughout the day, how would you describe your energy level from morning through evening? (ie. wake up rested or tired; mid-day droop; relaxed or wired in evening, etc)

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Throughout the week, does your overall energy tend to be the same from day to day, or does it vary depending on the day?

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Do you fall asleep easily?

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Do you take sleep medication or supplements?

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Do you wake up frequently at night? If so, why? (ie. to urinate; thought/worries/pain; etc)

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Do you awaken from sleep feeling rested?

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What is your family and/or community life like?

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Do you live alone or with other people / pets?

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Do you have friends, family nearby?

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What kinds of social and/or recreational activities do you regularly engage in?

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Do you have someone trusted to call upon if you need assistance or support?

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How would you describe your spiritual or religious life?

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How well do you feel you nourish yourself – with food, love, movement, laughter, other ways?

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What brings a sense of joy, peace, health, and balance into your life?

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How would you describe your state of mind most of the time?

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What is your experience with Yoga, meditation, or other mindfulness/wisdom practices?

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How often do you currently practice?

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What have you found most beneficial from these practices?

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What have you found most difficult or challenging?

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Have you had any previous Yoga injuries? How did they happen?

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What is the primary condition(s) for which you are seeking support through yoga therapy? Be as specific as possible.

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What is your main goal for Yoga Therapy? Be as specific as possible.

Do you have any additional comments / questions / concerns you’d like to address before we begin our work together?

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