Yoga Therapy Intake Questionnaire Name * First Name Last Name Date of Birth and Age * Address * Email * Phone Number * Emergency Contact * Current Occupation * Who referred you to me? * Do I have permission to receive information about your health from your healthcare provider? * Yes No If yes, what is your physician's name and contact information? Past or current medical history. Check all that apply: * Asthma Cancer Stomach/Digestive Conditions Depression Glaucoma Arthritis Diabetes Neurological Conditions Anxiety Muscle/Bone/Joint Condition(s) Hight Blood Pressure Heart/Lung Condition(s) Post-Traumatic Stress Disorder Autoimmune Disease Other (Please Specify Below) Other Condition(s) Past Surgical History. Please describe procedures and dates. * If none, state "none." What is your interest in Yoga Therapy? * Do you have background in yoga and/or meditation? If so, describe. * Have you consulted with a healthcare practitioner? If so, did you receive any diagnosis? If so, please describe. * Please describe any other course of treatment you are currently involved in and for what conditions (e.g., psychology, physiotherapy, Chinese Medicine): * Please list all current medications. * Rate your physical fitness and mobility. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your body awareness. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your nutrition. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your digestion. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your sleep quality. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your energy level. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your quality of breath. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your concentration/focus. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your memory. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your general mood. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your support systems. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your intuition. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your sense of belonging. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your feeling of being heard and understood. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your ability to observe your thoughts and patterns. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your sense of meaning and purpose in your life. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Rate your positive strategies and skills to manage overwhelming emotions. * Below Satisfaction Needs Improvement Satisfactory Very Satisfied Was there an event or events in your life that you would describe as traumatic? * What brings you happiness? * Describe a typical day in your life? * What do you do in your free time? * What are your specific goals/expectations from this kind of therapy approach? * Is there anything else you would like me to know about you? * Your form has been submitted. I will be in touch with you.-Dr. Monya
