Client Intake + Health History Form
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Client Intake + Health History Form
Name / DateEmail / Join our email list? Y N
Home phone / Preferred method of contact:
Cell phone / Email Home Phone Cell phone
Mailing address
Street address / City, State Zip
Emergency Contact| Name / Relationship to you
Phone number
YOGA EXPERIENCE + GOALS
Have you practiced yoga before? ____ No ____ Yes
If yes, approximate date of last class/practice______
How often do you practice yoga? {circle one} DAILY WEEKLY MONTHLY
Style{s} of yoga practiced:{circle all that apply}
Hatha Ashtanga Vinyasa/Flow Iyengar Power Anusara Bikram/Hot Forrest
Kundalini Gentle Restorative Yin Meditation {type}: ______
Chanting/Kirtan Other:______
What are your goals/expectations for your yoga practice? What benefits are you looking for? {circle all that apply, explain}
Strength training Flexibility General improvement in physical health
Stress relief Improve Body image Weight loss Emotional Balance
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Address health concern {please note details here and below}
Complementary/Alternative therapy {please detail specifics of your treatment at this time and in the past}
Personal Yoga Interests: {circle all that apply}
Asana // Postures Pranayama // Conscious Breathing Meditation // Mindfulness
Yoga Philosophy // Sanskrit studies Ayurveda // Holistic Nutrition Chanting
Other:
CURRENT HEALTH + HEALTH HISTORY
Please review this list and check those conditions that have affected your health either recently or in the past. Your health information is kept confidential and will never be shared.
___broken/dislocated bones___diabetes type 1 or 2
___pregnancy {if pregnant, EDD: ______}
___muscle strain/sprain
___high/low blood pressure
___surgery
___arthritis, bursitis
___insomnia
___back or disc problems
___anxiety/depression / ___scoliosis
___asthma, short of breath
___heart conditions, chest pain
___numbness, tingling anywhere
___auto-immune condition*
*AIDS, fibromyalgia, chronic fatigue, lupus, chronic allergies
___osteoporosis/osteopenia
___cancer {explain below}
Other/ Explain:
Please select any of the following symptoms you have had in the recent past or are experiencing now:
Night pain
Stroke
Severe psychological issues
Loss of sensation in an area of the body
Unremitting pain
Multiple joint complaints, especially in the morning
Joint deformity
Joint noise
Joint locking / Instability / Dislocation
Menstrual changes
Unexplained weight loss/gain
Loss of consciousness
Gait/balance changes
Loss of consciousness
Visual/speech impairment
Motor control problems {clumsiness, accidents, trembling, shaking}
Cardiovascular complaints {shortness of breath, racing heart, dizziness, feeling light-headed, fainting}
Positional headaches, such as headaches only when bending over or learning back
Unilateral complaints {one side of body only}
Night sweats
Bowel and bladder control problems
Recent trauma, such as car accident, fall, etc.
Swelling
Increased pain or radicular {“shooting”} signs
Please explain any of the check items…
Anything else you would like to address?
Turiya Yoga + Wellness , LLC turiyayogawellness.com