Yoga Therapy Intake Form Confidential Information Todays Date: Name___________________________ DOB ____________________________ Phone # _________________________Email ____________________________ Address__________________________________________________________

City__________________State__________________Zipcode_______________ Occupation__________________________Stress Level____________________ Emergency Contact (name and #)______________________________________ Yoga Practice Experience Have your practiced yoga before? YES (If yes, date of last practice) NO

How often do you practice yoga? (daily, weekly, monthly)? Styles of yoga practiced (circle all that apply): Hatha, Ashtanga, Vinyasa/Flow, Iyengar, Power, Kundalini, Gentle, Restorative, Bikram/Hot, Other Style(s) most practiced or preferred: Goals What goals to you wish to accomplish through yoga therapy (circle all that apply)? strength training flexibility balance improve overall fitness weight management stress reduction process loss/grief aid healing female issues increase personal well-being

Learn: proper alignment, postures (asana), breath work (pranayama), meditation Lifestyle Habits and Wellness Behaviors Fitness Behaviors: How do you rate you current level of activity (circle one)? Sedentary Somewhat Active Active Extremely Active

Describe you current workout/exercise: walking, hiking, cardio, gym membership, private trainer, etc. What is your workout frequency and duration? (i.e. daily / 1hr.) How would you rate you overall level of stress on a scale of 1 to 5 (1 is lowest and 5 is highest)? Complementary Therapies: Have you had any holistic alternative therapy? YES NO If yes, please circle what type(s): Acupuncture, Alpha-biotic Alignments, Chiropractic Adjustments, Body Work (Deep Tissue massage, Energy/Reiki, Maya Abdominal massage), Cranial Sacral therapy, Herbal/Naturopath supplements therapy, Hydro-colonics, Other(s) Reason and what was the outcome of therapy? Nutritional Behaviors: On an average day what do you eat? Describe: What are your eating patterns (circle): Healthy Choices: Describe types (i.e. raw, vegan, vegetarian, carnivore, organic foods) Fast Food(s): Describe what types and how often? Is this a lifestyle pattern? Stress induced eating: Describe triggers (emotions attached to behavior(s) On an average day what do you eat? Have you ever been on a specific type of diet for health purpose? Describe: Habit Forming Behaviors: Do you smoke? Yes No If yes, how many packs per day? Do you consider yourself a social drinker or drink excessively? Describe: Do you use recreational drugs? Yes No If yes, what type of recreational drugs and how often? Describe: Do you use pain medication? Yes No If yes, what was the reason for the prescription? What type of pain medication? How often? Are you addicted to any kind of substance abuse? Yes No If yes, what kind(s) of substance abuse

Are you in recovery? Yes If yes, how long?

No

Spiritual Awareness: Do you have a specific faith-base belief? What is it? How do you express your belief? How important is it to nurture and care for your spiritual well-being? On a scale from 1 to 5 rate the level of importance it is to develop and care for your spiritual well-being ( 1= lowest, 5 = highest) Do you desire a deeper spiritual relationship? Yes If yes, describe: No

Physical and Mental Health History Please review the following list and check condition(s) that have affected your health either recently or in the past: __broken/dislocated bones __muscle strain/sprain __arthritis, bursitis __disc problems __scoliosis __back problems __osteoporosis __Diabetes 1 or 2 __high/low blood pressure __insomnia __anxiety/depression __diagnosed mental health disorder(s) __asthma/shortness of breath __numbness/tingling anywhere __cancer-describe type: __pregnancy __female issues-describe: __surgery (surgeries)-describe: __seizures __traumatic brain injury

__strokes __heart condition/chest pain __auto immune deficiency conditions-describe __fibromyalgia __other(s) describe: Emotional Trauma: Have you ever been the victim of abuse? Yes No Circle type(s) of abuse: physical mental/emotional sexual neglect/abandonment Did you receive counseling/therapy? Do you have any trauma or crisis that entailed lost/grief? Yes No Describe: Did you receive counseling therapy? Are these issues you wish to address through holistic psycho-therapy? Yes Explain: No

Are you currently on any type of medication? If yes, please list names and reason for medication. Are you currently seeing a healthcare professional? If yes, please list name and reason/treatment. Please list any further information that you believe would be beneficial to your Holistic and Yoga Therapist to better assist you in meeting your health and wellness goals.

Thank you for taking time to fill this form. Gina Tricamo, R-MYT

CONSENT TO TREAT THROUGH YOGA THERAPY I understand that yoga therapy includes physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, adjust the posture and ask for support from the instructor. I understand that my Yoga Therapist may assist me in yoga postures. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I hereby agree to irrevocably release and waive any claims that I may have now or hereafter may have against Gina Tricamo. ____________________________________ Client __________________ Date

____________________________________ Yoga Therapist

__________________ Date