Confidential Client Intake Form for Yoga Therapy with kikayoga Contact Info Name * First Name Last Name Email Address * Phone * Country (###) ### #### Address Date of Birth * MM DD YYYY Your Goals What are your current reasons for seeking holistic yoga therapy? Do you have a goal for our time together? * What do you hope to achieve from private sessions? * Check all that apply Improve overall health Improve sleep Improve digestion Gain flexibiliity Build strength Improve balance Find peace of mind Learn strategies to relax Improve breathing Reduce stress Increase energy Learn how to meditate Learn how to do yoga poses safely and correctly Doctor/Health Care Professional recommended Develop a home yoga practice Lose weight Injury rehabilitation Other (please specify below) Please elaborate on any other reasons for working with me? Health History Do you have any of the following conditions: * check all that apply Allergies Anemia Anxiety/Depression Arthritis Asthma Autoimmune Condition Back Problems Broken Bones Cancer Chronic Fatigue Diabetes (Type 1) Diabetes (Type 2) Digestive Problems Dizziness, Vertigo Epilepsy Fibromyalgia Glaucoma Headaches Heart Condition Hearing Difficulty Hernia High Blood Pressure Low Blood Pressure Insomnia Joint Problem (please elaborate below) Muscle Strain/Sprain Osteoporosis Rheumatoid Arthritis Scoliosis Seizures Stroke Thyroid Imbalance Pregnancy Other (see below) None of the above Please elaborate and list any other injuries or conditions, including surgeries, accidents, medical diagnoses and approximate dates. How long has your current health condition been going on? Less than 3 months 12 months Over a year Chronic Who else are you currently seeing for your health concerns, including mental health therapy, acupuncture, MD, ND. How often do you see them? Please describe areas of discomfort and/or pain in your body. Try to describe where they are located and the type/degree of discomfort. What relieves your pain or discomfort? What increases your pain? Lifestyle & Digestion Briefly describe your typical diet. How is your digestion? Do you have daily bowel movements? Do you ever experience constipation, diarrhea, vomiting, excess gas or nausea? * What types of foods do you eat on a regular basis? What are your typical meals? Do you have any dietary restrictions or preferences? * Please list any vitamins and supplements that you are taking. How much water do you drink per day? * How many cups of caffeinated beverages do you drink per day? * Do you drink alcohol? If so, how many drinks per week? * Do you or have you ever smoked? * Is your daily schedule regular or does it change from day to day? Please describe. * Please describe your sleep habits. * Do you have any difficulty breathing? Do you notice changes in your breath when you become upset or agitated? * What are your perceived stress levels--low, moderate or high? Describe the possible stressors in your life. * Please check any of these emotions that you feel on a regular basis. * Worry Anxiety/Fear Overwhelm Spaced Our Insomnia Self-destructive indecisive Irritable Anger/Rage Aggression Jealousy Judgmental Intense Tension Lethargy Sadness Depression Greediness Attachment Procrastination Controlling Other (Please list below) Please list any other emotions and where you feel them. Experience with Yoga Have you ever practiced yoga before? Yes No If so, please share when you started doing yoga, what type of yoga and how often? Please click all types of yoga you have done. * check all that apply Flow Yoga/Vinyasa Hot Yoga Asthanga Kundalini Bikram Restorative Gentle Yin Yoga Meditation Iyengar I've never done yoga before What have you found most beneficial from these practices? What have your found most difficult and challenging? What other physical activities do you do and how often? * Final Thoughts Are there any habits or lifestyle behaviors that you would like to change? Is there anything getting in the way of your personal health or life goals? * What aspects of your life give you the most joy and pleasure? Where do you see yourself in 1 year, 5 years, 10 years? Anything else you would like me to know? Please list the best days and times for your session. * How much time can you devote to practicing yoga, breathing and self-care on your own time? * Thank you!
