Intake Form — Yoga Therapy with Rachel Breeding

Email

Age

Height

Weight

What are your current reasons for seeing a yoga therapist? Do you have a goal for our time together?

List your current and previous health conditions.

Please include medical diagnoses, surgeries, accidents, injuries, etc. and approximate dates.

How long has your current health condition been going on?

Who else are you currently seeing for your health concerns or general health promotion? How often do you see them?

Describe the areas of discomfort and/or pain in your body.

Try to describe where they are located and type/degree of discomfort. Rate your level of pain, using a scale of 1-10, 10 being the highest level of pain or discomfort.

What relieves your pain? What increases your pain?

What functional movements and tasks are difficult for you?

Examples: reaching, bending, picking up, twisting, walking up stairs, sitting for long periods of time, standing, etc.

What are your favorite physical movements? Least favorite? Do you have a regular exercise program? If so, please describe.

In percentages, how much of your day is spent in the following ways:

Sitting, driving, standing, desk work, lifting, lying down

What types of foods do you eat on a regular basis (at least 2x/week)?

Please include breakfast, lunch, and dinner foods.

What types of the following beverages do you drink regularly, and how much do you drink per day?

Water, caffeinated beverages, alcohol, non-caffeinated beverages

Number of bowel movements per day

Please list your current medications, vitamins, herbs, and supplements.

Please include how long you’ve taken it and your reason for taking it.

Please describe your overall energy level.

Does it fluctuate or stay consistent? When are you the most energized? Least energized?

Do you have difficulty breathing? Do you notice changes in your breath when you become upset or agitated?

Describe your sleep habits.

When do you normally turn off all digital media?

Describe the stress levels in your current life: low, moderate, high? What are the possible stressors?

Are there places in your body where these feelings tend to dwell when they come up? Please describe any list any additional emotions you can think of.

What life challenges are you currently facing?

Are there habits you would like to change?

Have you considered or are you already volunteering your time or talents?

What aspects of life give you the most joy and pleasure? What do you feel is your life’s calling?

How much time each day or week can you devote to your own personal yoga practice?

Yoga Therapy Intake Form

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