Client Intake + Health History Form

:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

Client Intake + Health History Form

Name / Date
Email / 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

:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

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