Yoga Therapy Intake Form – Simple As Pi Yoga & Meditation

I agree to give 24 hours notice for any cancellations or modifications to my scheduled appointment or I will be charged in full. I understand that time will not be added to my appointment for tardy arrival and I will be charged in full for my scheduled session.

Tick below or select 'other'

Improve Overall Health Improve Strength Improve Mobility Other

Other: What would you like to achieve out of your Yoga Therapy sessions?

Would you like to learn more about the following:

Do you have any current mental or physical health concerns you would like to focus on?

Have you practiced yoga before?

If yes, how often do you practice yoga?

How many times per - Day / Week / Month

What style/s of yoga have or do you practice?

Do you exercise?

Yes No

If yes, how often do you exercise per week?

Once a week Twice a week Three times a week More

Describe your current exercise practice:

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

If yes, please note down how many standard drinks per day/week/month

Tick the following that apply to your lifestyle:

Please describe your eating patterns.
For example, do you have a tendency to feel hungrier earlier in the day or later? Do you tend to eat an early dinner or late?
Do you regularly skip meals?

On a scale from 1 (low) to 5 (high), what is your current level of stress?

Do you have difficulty sleeping?

Yes No

What is the average amount of hours per night you sleep?

Please review this list and check those conditions that have affected your health either recently or in the past:

Auto Immune Condition(s) Type

Are you pregnant?

Yes No

Please briefly describe where you currently feel:

Physical Pain

Are you currently taking any medication?

Yes No

Please list any surgery(s) you have had, including dates.

Please list any other modalities you are currently using and why. (i.e. Physiotherapy, Chiropractic, Acupuncture, Deep tissue Massage etc.)

Therapy Options

Individual Therapy Group Therapy

Weekly Fortnightly Monthly Other

Thank you for all the time it has taken to complete this form. If there is anything else you wish to add, please write it below.

It is essential in your yoga practice that you take responsibility for your physical well-being. Please read and sign the following release:

• I understand that Yoga Therapy is not a substitute for medical advice: Yoga and Yoga Therapy is not a substitute for medical examination, diagnosis and/or treatment.
• I understand that it is my responsibility to consult with a physician prior to and regarding my participation in Yoga Therapy. I accept responsibility for informing the Yoga Therapist about any medical conditions, injuries, pregnancy or changes to my health that may affect my practice, prior to a class commencing.
• I understand that it is my responsibility to practise within my personal limits and to decide whether or not to follow the advice and guidance provided by the Yoga Therapist.

Welcome to your Private Yoga Therapy Intake Form

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