Client Intake Form - Yoga Doctors

How did you hear about YOGADOCTORS.TV?*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Skype Name (if Skype Patient)

Date of Birth*

Occupation*

Emergency Contact Name*

Emergency Contact Phone*

Briefly describe your condition/concerns and its impact on your daily life

What adjectives describe your pain/condition?

Please list any past or recent injuries that concern you

When did condition begin?

What makes condition worse?

What makes condition better?

Is your condition a result of an event such as a fall or car accident?

Have you had this condition in the past?

Have you had any other treatment for this condition (currently or in the past)

What area(s) of your body are the most tight?

What area(s) of your body are the most weak?

Please describe if you have any issues, tightness or weakness breathing and note if it is on the inhale or exhale:

Do you have an issues with incontinence (ie: urgency, frequency and/or leaking)?

Do you have any pain or dysfunction with sex?

Do you feel pressure or heaviness in your pelvis and/or pelvic floor?

What kind(s) of exercise do you do the most?

Do you do crunches and/or leg lifts?

Yes
No

Do you run?

Yes
No

How would you describe your digestion:

Do you tend to be more tired in the mornings or after you eat?

Yes
No

Please describe any issues you may have in the these areas and please note if it is right or left side (you can also put N/A if not relevant):

Head and/or neck:

If you get headaches, please note how often and where are they located (ie: front, back, sides of head, temples, feels like they originate in the neck)?

Shoulders:

Do you have any tingling, numbness, burning or electrical sensations down either arm?

Thoracic spine (Upper and mid back) and/or ribs:

Lower back:

Pelvis/Sacro-iliac (SI) Joint:

Do you have a leg length difference that you know of?

Do you ever feel like one leg is longer than the other when walking?

Do you have any tingling, numbness, burning or electrical sensations down either leg?

Have you ever experienced right or left-sided “sciatica”? If so, when and how often?

Do you experience any joint pain in the lower limbs?

Current medications:

Do the medications help your condition?

Please list any notable medical history:

Please list any surgeries:

Other health providers:

Do you feel there is an emotional component related to your pain?

Are you interested in addressing any repressed unconscious emotions that could be related?

Please comment on how you see yourself as a personality:

Please list the stressors in your life:

Have you been in psychotherapy or any other emotional therapies for this particular issue? Were they helpful?

How would you describe your quality of life during childhood and adolescence?

How would you describe your current relationship with your parents?

What are your specific goals for treatment?