Name
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First Name
Last Name
Birth Date
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MM
DD
YYYY
Please include location and time of birth, if known
Marital Status
Weight
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Height
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Occupation
Phone
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(###)
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####
Email
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What chief complain(s) bring you to yoga therapy?
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What are your hopes and goals in working with yoga therapy?
Will you dedicate 30-45 minutes, 3-5 times a week to a home practice? If not, how much time can you dedicate?
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When did the symptom(s) begin?
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Did the symptom(s) begin suddenly or gradually?
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Was there a specific incident that preceded the symptom(s)?
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What do you think is causing this problem?
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Have the symptom(s) changed since they began?
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Are the symptom(s) constant or intermittent?
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If intermittent, how often do you experience the symptom(s)? How long do the symptom(s) last?
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Do the symptom(s) occur at a specific time of day or night? When?
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Do the symptoms have an impact on your participation in your daily activities? If so, which ones (work, leisure, exercise, etc.)?
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What body positions aggravate the symptom(s) (standing, sitting, lying, etc.)?
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What body positions help alleviate the symptom(s) (standing, sitting, lying, etc.)?
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Do the symptom(s) interfere with your sleep? How?
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Is there any physical pain associated with the symptom(s)? How would you describe it (dull, sharp, throbbing, piercing, localized, shifting, etc.)?
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If applicable, rate the intensity of the pain on a scale of 1-10 (1= least pain, 10= most pain):
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N/A
1
2
3
4
5
6
7
8
9
10
Have you attempted to manage this issue or the symptom(s) on your own? How?
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Have you consulted a professional for this issue? Who? What was the diagnosis? What have they suggested?
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Do you currently take any medication for this or any other issue? What?
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Have you had any major illnesses or trauma? If so, what and when?
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What was the treatment, if any?
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Do you have a family history of this kind of condition or symptom? Of other conditions? If yes, please list.
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Have you had any recent life changes?
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How is your appetite?
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When are you hungry?
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What times of the day do you eat your meals?
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How do you feel after eating?
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Check all that apply
How's your elimination?
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Check all that apply
How's your urination?
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Check all that apply
What time do you usually go to sleep at night?
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What time do you wake up in the morning?
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Do you sleep through the whole night? If not, how often do you wake up?
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Do you experience any skin problems? If yes, please list.
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What are your average body sensations (hot or cold in face/hands/feet, chest tightness, stomach tightness, heart palpitations, etc.)?
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Do you sweat?
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How many hours a week do you work?
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What is your current stress level from 1 (no stress) to 10 (overwhelming)?
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1
2
3
4
5
6
7
8
9
10
When dealing with stressful situations, what is your normal reaction?
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Check all that apply
Do you get headaches? If so, how often?
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Tell us about your diet:
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How much water do you drink and how often?
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How much coffee or other caffeinated beverages do you drink and how often?
What is your general sugar/sweets intake (how much and how often)?
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Do you use tobacco? if so, how much and how often?
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Are you open to making dietary changes if they may help to alleviate your symptoms?
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Other important info:
Please provide any other health related information you feel is important to your appointment.
