Email Address

Occupation (if applicable):

Emergency Contact/Phone Number

OBJECTIVES

What do you want to achieve or change in terms of your health and wellness?

How would your life be different if you were to achieve these objectives to your satisfaction?

REVIEW OF CONCERNS

1. Please describe your chief complaint. If you have been diagnosed with a disease or condition, please list these as well.

2. When did the discomfort begin? Was there a particular incident that caused it?

3. Describe the areas where you feel pain, numbness, or chronic tension.

4. What is the level of pain from 1-10? (1 = mild; 10 = severe)

5. Is there a pattern to the pain in a typical 24-hr period?

6. What activities make the pain worse?

7. What activities makes the pain better?

8. Do you have any other medical conditions or health challenges? If so, please explain.

9. Medications & supplements you are currently taking and how often:

LIFESTYLE/DIET

1. What types of exercise and/or physical activity do you currently participate in and how often?

2. What are your work hours in a typical week?

3. How much of your day do you spend standing? Sitting?

4. How would you describe your energy levels?

5. How is your general stress level?

6. What types of situations trigger stress or bring it on for you?

7. What are some ways you find most effective for releasing stress?

8. Do you awaken from sleep feeling rested?

9. Do you fall asleep easily?

10. Do you wake up in the middle of the night and have trouble falling back asleep?

11. How many hours of sleep on average?

12. Describe what you typically eat for breakfast/lunch/dinner/snacks/beverages:

13. How do you have fun in your life?

14. Do you feel that you have sufficient emotional support?

15. Do you have any specific spiritual practices? If so, please describe:

16. What is your experience with yoga?

17. How much time would you be able to set aside daily for your yoga practice?

18. Any other questions/comments:

CLIENT INTAKE FORM