Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
DOB
*
What brings you to Yoga Therapy?
Do you have experience in Yoga Therapy, yoga, meditation, or other movement practices?
Do you have current and/or previous health conditions? You may include diagnosis, injuries, surgeries, etc. and approximate dates. And how long have you been experiencing the concern?
Are there any treatments you're using (providers, medication, supplements)?
What currently helps you feel better (medications/supplements, heat/ice, specific treatment, rest, exercise, self-care practices, movements etc.)?
Is there anything specific that makes you feel worse? (If so) Do you notice any discomfort/pain right away? Or only in the next few days?
Describe your current level of activity/exercise.
Have you recently or are you currently experiencing any life challenges/changes?
What you brings joy/meaning/pleasure?
Is there anything else you would like your yoga therapist to know?
How much time in your day/week would you like to commit to your yoga practices?
