Date of Birth
Have you ever attended a yoga class or worked with a Yoga Therapist?
Private ClassGroup ClassNone
When was the last time you practiced yoga?
This weekLast weekLast Month3 - 6 monthsMore than 6 monthsNever
Have you had a physical exam in the past year?
Physician Contact (Name/Address/Phone)
Do you work with a chiropractor?
Chiropractor Contact (Name/Address/Phone)
Please indicate if you are taking medication for any of the following conditions:
High Blood PressureDiabetesCancerAnxietyDepressionInsomniaGastrointestinalMigraine/HeadacheVitaminsN/AOther
If "Other", please list.
Why are you seeking yoga therapy?
Please indicate any forms of alternative care you have used.
(Ex: massage therapy, aromatherapy, reiki, etc.)
Are you interested in nutritional counseling?
Please add any other pertinent information you would like us to know.