Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

3. Do you experience any pain or discomfort? *

Yes

No

5. Have you ever practiced yoga before? *

Yes

No

6. Do you engage in other forms of movement or exercise? *

Yes

No

1. How would you describe your stress level? *

Low

Moderate

High

4. How is your sleep? *

Restful

Interrupted

Insomnia

Other:

5. How is your digestion? *

Comfortable

Sensitive

Constipation

Other:

1. What are your goals or intentions for yoga therapy? *

Reduce Pain

Increase mobility

Improve sleep

Manage anxiety or depression

Enhance strength or endurance

improve posture or balance

Other:

2. Do you have preferences regarding the type of practice? *

Gentle movement

Strength-based

Restorative/Yin

Breathwork

Meditation

Other:

3. Do you prefer hands-on assists (with consent each time)? *

Yes

No

Unsure

Date *

MM

DD

YYYY