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Client Form
Home
Retreats
Retreats
Corsica 2024 Booking Form
Retreat Evaluation
Retreat Gallery
About
Sabbatical travel
Classes
Yoga Therapy
Client Form
Contact
BOOKINGS
Client Form
Confidential Information
Please complete and submit the form below
Name
*
First Name
Last Name
Email Address
*
Mobile phone number
*
DOB (dd/mm/yyyy)
*
Address
Emergency Contact Name and Telephone Number
*
Occupation
Do you live alone or with another person (s)
Reasons for seeking out yoga therapy and goals you wish to accomplish through yoga therapy
Yoga Experience
None
Limited
Intermediate
Advanced
Have you had experience with any of the following
Pranayama (breath work)
Meditation
Chanting
Medical Conditions (eg, asthma, allergies, diabetes, cancer, heart conditions, scoliosis, arthritis, eating disorder, epilepsy, high/low blood pressure, anxiety, thyroid, gut/digestion, headaches, migraine, other ..)
Please provide information regarding duration of condition and treatment
Please describe any major illnesses you have or have add. Provides dates and treatments.
Are you under the guidance of another from of practitioner? Eg: GP, Physio, naturapath.
Current medications (include complimentary, herbal or supplements) Note any side effects
Reproductive Health
Please tick the box if any of these apply to you
Pregnant
Menopausal
Suffer irregular or painful menstrual cycles
Undergoing treatment for infertility
Describe any Injuries (current and previous)
Are you currently experiencing pain?
If so, how would you describe the level of pain and in which part of the body?
What is your current activity level?
Low
Somewhat active
Moderately active
Very active
Types of activity/exercise
Note type, duration and frequency (eg: walk 1hr x 2 week)
Rate your level of stress
on a scale from 1-10 with 1 being the lowest and 10 the highest
1
2
3
4
5
6
7
8
9
10
Rate your level of energy
on a scale from 1-10 with 1 being the lowest and 10 the highest
1
2
3
4
5
6
7
8
9
10
Rate your level of sleep
on a scale from 1-10 with 1 being the lowest and 10 the highest
1
2
3
4
5
6
7
8
9
10
Briefly describe your diet (include any foods you deliberately omit from your diet)
How much water do you drink per day?
My spiritual well being is important to me
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Privacy Statement and Agreement
As a yoga therapy client, personal information and a record of your care and services will be created. This record is required to provide you with personalised, quality care. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. We take reasonable steps to ensure your personal information is protected from misuse and loss and from unauthorised access, modification or disclosure. We may hold your information in either electronic or hard copy form. Personal information is destroyed or de-identified when no longer needed. Conditions of Practice I understand that yoga involves physical exertion and undertake to be aware and responsible for my own personal safety during practice. I will advise my therapist of any injuries, surgery, pregnancy or other physical limitations prior to practice.
I have read and agree to the Privacy Statement and Conditions of Practice
Thank you!
