Yoga Therapy Intake Form
1. Name____________________________________________________________
2. Address__________________________________________________________
3. Email____________________________________________________________
4. Daytime Phone____________________________________________________
5. Home Phone______________________________________________________
6. Age_____
7. Date of Birth________________
8. Emergency Notification______________________________________________________
9. Primary Care Physician_______________________________________________________
10. Do you have any experience with stress management, yoga or meditation(please describe)? Where
do you practice, if you practice outside the home?
_________________________________________________________________________________
_________________________________________________________________________________
11. What are your reasons for seeing a Yoga Therapist?
12. How would you describe your health overall?
_________________________________________________________________________________
_________________________________________________________________________________
13. Are you satisfied with your posture?
_________________________________________________________________________________
_________________________________________________________________________________
14. What kind of work do you do?
_________________________________________________________________________________
_________________________________________________________________________________
15. Are you comfortable at work?
_________________________________________________________________________________
_________________________________________________________________________________
16. What are your recreational activities and how often do you participate in them?
_________________________________________________________________________________
_________________________________________________________________________________
17. Is your daily schedule regular or does it change from day to day?
_________________________________________________________________________________
_________________________________________________________________________________
18. Do you notice changes in your breathing when you become upset or agitated?
_________________________________________________________________________________
_________________________________________________________________________________
19. Are you currently or were you ever a smoker?
_________________________________________________________________________________
_________________________________________________________________________________
20. What is your overall energy level? Scale of 1-10 with 10 being extremely high. _________________
21. Would you describe your energy level as stable or quite variable?
_________________________________________________________________________________
_________________________________________________________________________________
22. Do you get to sleep easily and rest well through the night?
_________________________________________________________________________________
_________________________________________________________________________________
23. Do you wake up refreshed and ready to start your day? ___________________________________
24. If there are energy fluctuations, when do you feel them? __________________________________
25. What is your stress level? ___________________________________________________________
26. What tends to bring on or trigger stress for you?
_________________________________________________________________________________
_________________________________________________________________________________
27. List your current and previous health conditions. Please include medical diagnoses, surgeries,
accidents, injuries, etc., and approximate dates.
_________________________________________________________________________________
28. Do you have a diagnosis from a physician? Please describe.
_________________________________________________________________________________
_________________________________________________________________________________
29. Are you currently seeing a health care provider and if so, for what?
_________________________________________________________________________________
_________________________________________________________________________________
30. Do you experience anxiety, sadness or depression? Are there places in your body where these
feelings tend to dwell?
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
31. What would you like most to gain from yoga therapy?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
32. Please list all medications and supplements currently in use and the reason for each.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
33. Do you have or have you had any of the following? Please highlight in bold any that apply if typing,
or if writing by hand, circle the appropriate items.
HIGH BLOOD PRESSURE
ASTHMA
GLAUCOMA
VISION DIFFICULTIES
OSTEOPOROSIS
CHEST PAIN
SEIZURES
SHORTNESS OF BREATH
RHEUMATOID ARTHRITIS
NIGHT SWEATS
ANEMIA
JOINT SWELLING
HEART PROBLEMS
TRAUMATIC AUTO ACCIDENTS
BLADDER OR BOWEL CONTROL PROBLEMS
MAJOR SURGERY(DESCRIBE)
PINCH NERVES OR DISC PROBLEMS
HEADACHES
CANCER
MENOPAUSAL CHALLENGES
BROKEN BONES
ARE YOU PREGNANT?
ALLERGIES
CESAREAN DELIVERY
BLOOD THINNERS
EARLY ONSET MENOPAUSE
NEUROLOGICAL DISEASE
Participation in Yoga classes includes, but is not limited to, participation in meditation techniques, yogic breathing
techniques, and performing various Yoga postures. Yoga postures, or asanas, are designed to exercise every part of
the body - stretching and toning the muscles and joints, the spine and the entire skeletal system. They also work
on the internal organs, glands and nerves. Yoga incorporates sustained stretching to strengthen muscles and
increase flexibility.
Yoga and physical exercise is an individual experience. I understand that in Yoga, and in any other exercise class, I
will progress at my own pace. If at any point I feel overexertion or fatigue, I will respect my own body's limitations
and I will rest before continuing Yoga or any other exercise.
By signing my name below, I acknowledge that participation in Yoga classes or any other exercise class exposes me
to a possible risk of personal injury. I am fully aware of this risk and hereby release Mint Hill Yoga, Bettie Alston
Shea, and / or any other persons who may teach at Mint Hill Yoga, from any and all liability, negligence, or other
claims, arising from, or in any way connected, with my participation in Yoga and any other exercise class.
My signature further acknowledges that I shall not now, or at any time in the future, bring any legal action against
Mint Hill Yoga, Bettie Alston Shea, and/or any other persons who may teach at Mint Hill Yoga; and that this waiver
is binding on me, my heirs, my spouse, my children, my legal representatives, my successors and my assigns.
My signature verifies that I am physically fit to participate in Yoga classes, or any other exercise classes, and a
licensed medical doctor has verified my physical condition for participation in this type of class.
If I am pregnant, or become pregnant, or am post-natal, my signature verifies that I am participating in Yoga, or
any other exercise classes, with my doctor's full approval.
I realize that I am participating in Yoga, or any other exercise classes, at my own risk.
My signature is binding to this liability waiver from this day forth.
Date _________________________
Signature ________________________________________
IF UNDER 18 YEARS OF AGE
As legal guardian of ________________________________, we consent to the above conditions.
Signature of Guardian: _______________________________