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:



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?

What adjectives describe your pain/condition?

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?

Current medications:

Do the medications help your condition?

History and dates of surgeries:

What are your specific goals?

Other health providers:


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.