Yoga Therapeutics
Assessment Form
Welcome. We look forward to working with you. Because therapeutic yoga can address the spectrum of human issues
and challenges, including and beyond physical pain and injury, we ask that you please answer these questions. Feel free
to use the back if you need more space. Please note that all of your personal information will be kept confidential.
Name:
Address:
Phone:
Email:
Physician:
Date of Birth:
Age:
Current or most recent employment:
How did you hear about us?
Yoga Practice Experience
1. Have your practiced yoga before?
YES
NO
2. If yes, how often do you practice?
3. Styles of yoga practiced (circle all that apply): Ashtanga Bikram/Hot Gentle/Restorative Hatha Iyengar
Kundalini Power Restorative Vini Vinyasa/Flow Other
Goals
1. What do you hope to gain through yoga therapy? (circle all that apply and feel free to add)
Physical - strength training, injury recovery, flexibility, weight management
Mental/Emotional – depression, anxiety, recovery and/or maintenance, grief, changing or improving
Health/behavior habits
Spiritual – please describe
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
Yoga practice improvement: asanas, alignment, pranayama/breathwork, meditation______________________
Other
Challenges
1. Please describe your chief complaint including the initial onset, the frequency (e.g. all the time, only at night, etc.):
2. Please indicate your level of pain/discomfort on a scale of 1-10 (10 being unbearable):
3. Are you seeing a health care provider for this complaint? (if yes include name)
4. Please describe your discomfort. Is it mainly physical or emotional? If physical - where does it start and end? Is it
superficial or deep? Does it feel like muscle, bone, nerve, connective tissue, scar tissue? If emotional, where do
you feel it in your body and what does it feel like?
5. What makes your discomfort feel better and what makes it feel worse?
Health History
1. Please describe any illnesses or injuries, physical or emotional , including onset, diagnosis and symptoms:
2. Do you have any digestion issues? (e.g. heartburn, stomach or intestinal pain, diarrhea, constipation, parasites):
3. How often do you have a bowel movement?
4. Please list any surgeries or hospitalizations:
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
5. Are you currently being treated for any illnesses or injuries?
REVIEW OF SYSTEMS – please circle N for “no” or Y for “yes”
Constitutional
Recent Weight Change
Fever
Fatigue
Gastrointestinal
Poor Appetite
Difficulty in Swallowing
Heartburn
Nausea or Vomiting
Bloating
Belching
Regurgitation
Constipation
Diarrhea
Abdominal Pain
Recent Change in Bowel Habits
Rectal Bleeding
Black, Tarry Stools
N
N
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Eyes
Blurred Vision
Glaucoma
N
N
Y
Y
Ears/Nose/Mouth/Throat
Hearing Loss
Ringing in Ears
Mouth Sores
N
N
N
Y
Y
Y
Cardiovascular
Chest Pain
Shortness of Breath
Swelling of Ankles
N
N
N
Y
Y
Y
Neurological
Headaches
Seizures
Strokes
Numbness
N
N
N
N
Y
Y
Y
Y
Respiratory
Chronic Cough
Spitting up Blood
Wheezing
N
N
N
Y
Y
Y
Psychologic
Memory Loss or Confusion
Depression
N
N
Y
Y
Genitourinary
Burning with Urination
Blood in Urine
N
N
Y
Y
Endocrine
Heat or Cold Intolerance
Excessive Thirst or Urination
N
N
Y
Y
Musculoskeletal
Joint Pain or Swelling
Back Pain
Muscle Pain
N
N
N
Y
Y
Y
Hematological
Bleeding or Bruising Tendency N
Anemia
N
Past transfusion
N
Y
Y
Y
Skin
Rash
Itching
N
N
Y
Y
Are you Pregnant?
Y
N
Comments/Concerns:
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©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
Structural Issues
1.
Please describe any pain or discomfort you have in your body.
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2.
Please circle the areas in your body where you feel pain or discomfort. On a scale from 1-10 give a value to
that pain or discomfort next to the area that you circle.
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
Habits and Lifestyle
1. Please describe your diet. What do you eat on a typical day for breakfast, lunch, dinner and snacks?
2. How much water do you drink in a day? Other liquids?
3. Please list any medications/supplements you are taking:
4. What kind of therapies do you use or have you used in the past (e.g. acupuncture, herbal medicine, etc.)
5. In a typical 24 hour day, how much time to you spend sitting, standing, walking/exercising, lying down?
6. What do you do for work?
7. Do you exercise regularly? Please describe:.
8. How do you sleep? How many hours a night and what times?
9. Do you have a regular schedule or does it vary? Do you travel a lot?
10. Do you drink alcohol? How much/frequency?
11. Do you drink caffeine? How much/frequency?
12. How much sugar/sweets do you eat in a typical day?
13. Do you eat when you are stressed?
14. Do you smoke?
15. Please describe any past or current recreational drug use:
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
Energetic Considerations
1. Do you have any breathing issues? Would you like to learn breathing practices to help manage symptoms and
mood?
2. How is your energy level in general? Which times of day do you have more energy? Which times less? Do you
have energy “crashes” and if so at what time of day?
3. Are you affected by other people’s energy? Please describe.
Mental Emotional Considerations
1. Please describe any mental/emotional conditions you have or have had in the past including depression, anxiety,
addictions, eating disorders, traumas, etc.
2. Are you currently facing any life challenges or transitions? Please describe:
Self-Expression Considerations
1. Do you feel you have scope in your life to express yourself creatively? What kinds of activities help you feel
connected and like you are expressing yourself?
Social Considerations
1. Do you have a good support system? If not, what kind of changes would you like to make in this area?
2. Do health concerns ever make you feel isolated or disconnected?
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
3. Are your relationships mostly nurturing or stressful? Do you feel supported by the people closest to you?
4. Are you experiencing any kind of abuse currently or have you experienced it in the past?
5. What kind of community do you have and do you feel supported by it, (e.g. church, organizations etc.)?
Spiritual considerations
1. Do you have a set of practices that help you to feel spiritually connected? Please describe:
2. Do you desire a deeper spiritual connection? Please explain:
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.
Release and Liability Waiver
Please ask for clarification on any portion that you do not understand. Please initial after each statement indicating that
you understand and agree to the statement:
1. I understand that Yoga Therapy incorporates movement and that there is always an inherent risk when
participating in physical activities. I agree to let the therapist(s) know of any physical limitations I might have, or
any physical activities I do not wish to participate in. _______(initial)
2. I hereby release _____________________ from responsibility for any injuries I may sustain as a results of
participation in this program. _______(initial)
3. I have read the above waiver and agreement and have fully understood its contents. By signing below, I am fully
agreeing to all of the above statements.
Signature:____________________________________________________Date:_______________________________
©2012. Sarva Health Systems. May be reproduced by students of the Subtle Yoga Therapeutic Teacher Training program.