CLIENT INTAKE FORM

Today's Date:

How did you hear about YOGADOCTORS.TV?

Full Name:

Home Address:

City, State & Zip:

Mobile Phone:

Email:

Date of Birth:

Occupation:

Emergency Contact Name:

Emergency Contact Phone:

Briefly describe your condition/concerns:




PHYSICAL BODY



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?

Current medications:

Do the medications help your condition?

History and dates of surgeries:

What are your specific goals?

Other health providers:


ENERGY BODY & EMOTIONS


ROOT CHAKRA



1.Are you confident things will work out for you, whether it be money, relationships or career?

2.Do you have rigid boundaries and find it difficult to accept change?

3.Do you feel disconnected from your own body and the world around you?


SACRAL CHAKRA



4.Are you open to intimacy and have a great passion for life?

5.Do you tend to be over-emotional and have a lot of drama in your life?

6.Do you lack creativity and deny yourself things that feel good?


SOLAR PLEXUS CHAKRA



7.Do you feel you are run by your ego?

8.Do you tend to be angry, aggressive and always want it your way?

9.Do you have a lot of doubt, mistrust and worry about other people and feel like you aren’t good enough?


HEART CHAKRA



10.Are you kind, caring, accepting and feel at ease with yourself and others in your life?

11.Do you feel ruled by your emotions?

12.Do you have a hard time trusting or feel unloved, unworthy and unappreciated?


THROAT CHAKRA



13.Do you honestly express yourself and how you feel to those around you?

14.Are you overly critical or opinionated and do not allow others to voice their opinion?

15.Are you considered “flakey” by others and have a hard time being honest?


THIRD EYE CHAKRA



16.Do experience higher states of consciousness and understand you are the Creator of your reality?

17.Are you judgmental and over-intellectual?

18.Do you feel disconnected from your intuition?


CROWN CHAKRA



19.Do you feel connected to your spiritual self and see others as part of you, rather than separate?

20.Do you have trouble grounding yourself or do others consider you “out there”?

21.Are you connected to your purpose in life and is it easy for you to accept new ideas or positive outlooks on life?


PERSONALIZED YOGA VIDEO



Will you be practicing your video in the morning, evening or both?

Are you open to having meditation included in your video?

Do you resonate with a certain style of Yoga?

Are you interested more in Hatha Yoga (Yoga for physical alignment, strength, balance and/or flexibility) or Kundalini Yoga (Yoga for the Energy Body and raising consciousness)?

Are you flexible with the time of your video or do you need it to be exactly 30 minutes? If less, please specify time.