Confidential Client Form - Yoga | Melissa's Healing Space

Name:*

Email*

DOB*

Gender

Weight

Height

Address

Street Address City State / Province / Region ZIP / Postal Code

Country of Birth

Phone

Emergency Contact

Emergency Phone

Occupation

Do you live alone?

General known medical conditions - please tick:

What would you like to focus on in the yoga therapy session? Please try and be specific:

• Do you smoke or have you ever?

• How often would you drink alcohol?

• Is your monthly cycle regular?

• Are you Menopausal?

• Do you have broken sleep?

• Please describe any major illnesses, conditions, surgeries you have had, or still have & the treatment.

• What makes it better or worse.

• If you were to rate your pain in these areas with 10 being the highest, what would it be?

• Are you currently having any other treatments eg: physio, acupuncture, chiro:

• Other conditions if they were not listed:

• Medication & it’s purpose if any, including complementary or herbal remedies:

• Level of Fitness:

• What do you currently do for exercise:

• What brings you joy, hobbies etc:

• Degree of stress in your life. What makes it worse? What improves it?

• Do you have or have you had any anxiety, depression, feelings of being overwhelmed, mood changes or other feelings. What strategies do you use to deal with any of these that you have experienced?

• What yoga have you done in the past, current classes, style of practice, home practice?

• Do you have experience in pranayama, chanting, meditation & relaxation from yoga or other disciplines? Please describe:

• For yoga therapy to be beneficial, your personal practice should be a daily part of your routine. Works well to trial it over a 3-week period. Can you suggest how much time suits you each day for your personal practice?

• Is there anything else about you & yoga that you would like to mention?

Consent*

While the yoga instruction is coming from an accredited and highly qualified and experienced yoga therapist, I understand that yoga involves being aware and responsible for my practice to ensure my personal safety.

I agree.

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