First Name

Last Name

Date of Birthday

Occupation

Mobile Phone

Email Address

Address

City

State

ZIP Code

Emergency Contact Name

Emergency Contact Phone

Reason for your visit

What is your primary issue?

How often do you experience your symptoms? How often do you experience your symptoms? Constantly (76-100% of the time) Frequently (50-75%) Occasionally (26-50%) Intermittently (up to 25%)

When did you first notice it?

What activities provide relief?

What makes it worse?

How are your symptoms changing with time? How are your symptoms changing with time? Getting worse Staying the same Getting better

Have you tried any other therapies or treatments? Have you tried any other therapies or treatments? Yes No

Describe your sleep recently

What do you hope to accomplish? What do you hope to accomplish? Body awareness Muscle Strengthening Improve other body systems Diet and lifestyle Digestion and elimination Specific Yoga postures or practices Improve energy level Breath awareness Less trouble handling emotions Less anxiety or depression Finding greater fulfillment at work Muscle stretching and flexibility Stabilization of joints Pain reduction Overall posture improvement Improve breathing Improve sleep Overall stress reduction Less reactive / upsetting More satisfying personal relationships Greater sense os sle-esteem Other goals

How much time per day can you devote to doing yoga or healing work?

HEALTH HISTORY : Are you currently under a physician’s care for an acute or chronic issue? HEALTH HISTORY : Are you currently under a physician’s care for an acute or chronic issue? Yes No

If yes, please explain

Health Care Provider

Date of last Physical Exam

What do you do for relaxation/exercise?

Do you regularly and/or participate in any sport? Do you regularly and/or participate in any sport? Yes No

If yes, which sport?

Have you recently suffered an injury? Have you recently suffered an injury? Yes No

If yes, please explain your injury

Are you uncomfortable in any of the following areas? Are you uncomfortable in any of the following areas? Gluteal Region Pectoral Region Face / Scalp Feet No

Please list any medications (vitamins, herbs or pharmaceutical) you are currently taking or at regular intervals

Please list any injuries/accidents/illnesses or surgeries still affecting you and how you have been caring for them

Do you experience stress in your work, family or other aspects of your life? Do you experience stress in your work, family or other aspects of your life? Awful Not very good Good Really good Excellent

And how you believe it affects your health? And how you believe it affects your health? Muscle tension Anxiety Insomnia Irritability Digestive disturbances Other

How are you feeling? How are you feeling? Anxious Bored Cold Confident Curious Disappointed Disgusted Exhausted Happy Hot Hysterical Interested Lonely Satisfied Surprised Thoughtful

Please indicate ANY PRESENT CONDITIONS Please indicate ANY PRESENT CONDITIONS ADD/ADHD Allergies Alzheimer's Disease Anxiety Disorder Arthritis Athletes Foot Asthma Blood Clot / Deep Vein Thrombosis / Phlebitis / Embolism Broken or fractured bones Bursitis Carpal Tunnel Syndrome Cerebral palsy Chronic Fatigue Syndrome Contagious Condition Crohn's Disease Depression Diabetes type 1 Diabetes type 2 Diverticulitis Eczema Epilepsy Epstein Barr Fertility concerns Fibromyalgia General fatigue Gout Headaches Hearing impairment Heart Condition Herpes / Shingles High / Low Blood pressure High / Low Cholesterol VIP / AIDS Lupus Lymph Edema Metal implants / artificial joints Mononucleosis Multiple Sclerosis Muscular Dystrophy Numbness / Tingling Osteoporosis / Osteopenia Osteoarthritis Pain Paralysis Rheumatoid Arthristis Rheumatoid Arthritis Chronic Parkinson's Disease Pregnancy Psoriasis Rash Sciatica Scoliosis Seizure Sleeping problems Spams / Sprain Stroke Tendonitis Thyroid Issues TMJ / Jaw pain Tumor malignant Tumor benign Varicose Veins Vertigo, dizziness or loss of balance OTHER

Comments

Please indicate ANY PAST CONDITIONS Please indicate ANY PAST CONDITIONS ADD/ADHD Allergies Alzheimer's Disease Anxiety Disorder Arthritis Athletes Foot Asthma Blood Clot / Deep Vein Thrombosis / Phlebitis / Embolism Broken or fractured bones Bursitis Carpal Tunnel Syndrome Cerebral palsy Chronic Fatigue Syndrome Contagious Condition Crohn's Disease Depression Diabetes type 1 Diabetes type 2 Diverticulitis Eczema Epilepsy Epstein Barr Fertility concerns Fibromyalgia General fatigue Gout Headaches Hearing impairment Heart Condition Herpes / Shingles High / Low Blood pressure High / Low Cholesterol VIP / AIDS Lupus Lymph Edema Metal implants / artificial joints Mononucleosis Multiple Sclerosis Muscular Dystrophy Numbness / Tingling Osteoporosis / Osteopenia Osteoarthritis Pain Paralysis Rheumatoid Arthristis Rheumatoid Arthritis Chronic Parkinson's Disease Pregnancy Psoriasis Rash Sciatica Scoliosis Seizure Sleeping problems Spams / Sprain Stroke Tendonitis Thyroid Issues TMJ / Jaw pain Tumor malignant Tumor benign Varicose Veins Vertigo, dizziness or loss of balance OTHER

Comments

Please indicate ANY REOCCURRING CONDITIONS Please indicate ANY REOCCURRING CONDITIONS ADD/ADHD Allergies Alzheimer's Disease Anxiety Disorder Arthritis Athletes Foot Asthma Blood Clot / Deep Vein Thrombosis / Phlebitis / Embolism Broken or fractured bones Bursitis Carpal Tunnel Syndrome Cerebral palsy Chronic Fatigue Syndrome Contagious Condition Crohn's Disease Depression Diabetes type 1 Diabetes type 2 Diverticulitis Eczema Epilepsy Epstein Barr Fertility concerns Fibromyalgia General fatigue Gout Headaches Hearing impairment Heart Condition Herpes / Shingles High / Low Blood pressure High / Low Cholesterol VIP / AIDS Lupus Lymph Edema Metal implants / artificial joints Mononucleosis Multiple Sclerosis Muscular Dystrophy Numbness / Tingling Osteoporosis / Osteopenia Osteoarthritis Pain Paralysis Rheumatoid Arthristis Rheumatoid Arthritis Chronic Parkinson's Disease Pregnancy Psoriasis Rash Sciatica Scoliosis Seizure Sleeping problems Spams / Sprain Stroke Tendonitis Thyroid Issues TMJ / Jaw pain Tumor malignant Tumor benign Varicose Veins Vertigo, dizziness or loss of balance OTHER

Comments

Do you have CANCER? Do you have CANCER? Yes No

Cancer location

Cancer treatment

Please identify the areas of concern using the HUMAN BODY CHART FRONT AND BACK at the end of this form. Select the side, zone and type of discomfort you’re experiencing.

FRONT RIGHT FRONT RIGHT Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6

FRONT LEFT FRONT LEFT Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6

BACK RIGHT BACK RIGHT Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6

BACK LEFT BACK LEFT Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6

Please identify the areas of concern using the HUMAN BODY CHART RIGHT AND LEFT SIDE at the end of this form. Select the side, zone and type of discomfort you’re experiencing.

RIGHT SIDE RIGHT SIDE Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6

LEFT SIDE LEFT SIDE Sharp pain Burning, radiating pain Numbness Dull ache

In which zones? In which zones? 1 2 3 4 5 6