HEY Therapeutic Yoga Intake Form HEY Therapeutic Yoga Intake Form Step 1 of 5 20% First Name* Last Name* Email* Date of Birth MM slash DD slash YYYY Occupation Telephone Number Preferred Teacher Emergency Contact Emergency Contact Telephone Number Emergency Contact Relationship Have you practiced yoga before?YesNoDescribe your yoga practiceWhat brings you here today and what would you like from this session?Are you under the care of a medical professional or other health care provider?YesNoIf yes, for what?Please mention sprains, breaks, surgeries or mobility issues Have you ever been told that you have heart disease, high blood pressure or that you have had a stroke? Heart Disease High Blood Pressure Stroke None of the above Have you had any accidents or injuries, hospitalization or surgeries?YesNoIf yes, please explain:What medications have you taken in the past 6 months or currently?Do you exercise regularly?YesNoIf yes, how frequently and describe what type of exercise you do: Do you have any specific bodily discomfort or areas in the body that are painful?YesNoIf yes, please describe here and answer questions below pertaining to the pain.Have you seen a physician for your pain and was there a diagnosis?YesNoPlease describe diagnosis?When did the pain first occur?Is the pain constant or infrequent?ConstantInfrequentWas the pain slow to come on or did it happen suddenly?Slow to come onSudden painWhere is the pain?On a scale of 1-10 how painful is it feeling today?12345678910What brings the pain on?What makes it feel better?In general, is the pain getting worse, better or staying the same?WorseBetterSameDo you have any numbness, numb-like sensations, pins and needles?Does the pain spread up the back, down the hip or leg, or into the foot?Have you had treatment for the pain, what and was it effective? Have you ever had any of the following conditions/illnesses/problems (check all that apply)? Spinal/Skeletal problems Stroke history Dizziness Depression Joint Swelling or Dislocation Muscular injuries/Disease Circulatory problems Skin disorders Trauma Artificial Joints Reproductive problems Pregnancy Insomnia Back pain Numbness/ Tingling Arthritis Anxiety Seizures Elimination problems Fatigue Headaches Cancer Liver disease Diabetes Allergies/Asthma Respiratory Problems Osteoporosis/Osteopenia Heart condition M.S./Nuerological conditions Infectious disease High/Low blood pressure Fibromyalgia/Chronic Fatigue None of the above Please describe your health condition(s) or any other concerns below:Is there anything else you think I should know?Are you ready to make significant changes to find relief for your conditions?YesNoHow much time a day are you willing to devote to your healing?Waiver of Liability and Confidentiality I understand that yoga involves some physical exertion and stretching, and I agree to take full responsibility for not exceeding my limits in the practice of yoga and for any injury or discomfort I might experience in the practice of yoga. I understand and accept that to properly teach and correct yoga technique, physical contact between student and instructor may be necessary. I consent to such contact and recognize that the instructor will apply any necessary contact in a professional manner. I understand that this document and it’s information will be kept in confidence and is confidential. The Teacher may not be a medical authority and is not qualified to diagnose or prescribe any “therapy.” The teachings presented are voluntary suggestions. The information presented is personal opinion based upon experience. Your Doctor or chosen Health-Care-provider's clearance for you to participate in a private session is highly recommended. Obtaining such clearance is your sole responsibility before you participate. Please seek medical care for whatever condition you may have.Please enter your name below to agree to the Waiver of Liability and Confidentiality* Date MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
