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Yoga Therapy Intake Form

Please complete this intake form and we will be in touch to discuss organising your initial consult.

Click the button below to start.

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PERSONAL INFORMATION

Your Full Name 

Question 2 of 18

New Question

Question 3 of 18

Your Contact Number

Question 4 of 18

Your Email Address 

Question 5 of 18

Your Home Address 

Question 6 of 18

Your Date of Birth 

Question 7 of 18

Occupation (including tme i me in the current occupation. Please note prior occupation if there has been a change in the last few years. 

Question 8 of 18

Yoga/Meditation/Mindfulness experience (including style of practice, outline daily/weekly practice schedule and years practicing)

Question 9 of 18

What would you like to gain from these sessions? emotionally, physically, mentally…

Question 10 of 18

Do you (or have you ever suffered from) 

(Select all that apply)
A

Stress related tension

B

Digestive issues

C

Asthma/lung conditions

D

Chronic pain

E

Circulatory/Heart condition

F

Fatigue

G

Headaches/migraines

H

High blood pressure

I

Low blood pressure

J

Sleeping difficulties

K

Menopause problems

L

Depression

M

Weight loss

N

Weight gain

O

Back pain

P

Neck pain

Q

Intervertebral disc problems

R

Knee problems

S

Hip problems

T

Arthritis

U

PMT

V

PTSD

W

Anxiety

Question 11 of 18

If you ticked any on the last question please outline more information here

Question 12 of 18

Outline any medical conditions (including allergies)

Question 13 of 18

Have you had any surgeries? If yes please outline below including years of surgery and any side effects

Question 14 of 18

Current Medication (including the time of day the medication is taken and any side effects)

Question 15 of 18

Please list other health professionals on your support team including contact details including GP, psychologist, speech pathologist, physiotherapist, OT, case manager etc 

Question 16 of 18

Emergency contact including name, relationship and contact details

Question 17 of 18

Any additional information you feel we need to know.

Question 18 of 18

I hereby consent to Sarah Truman providing me Yoga Therapy.  I acknowledge that this may include physical, psychological, & subtle strategies, & that it is my responsibility to inform my therapist if any practices cause me any distress or discomfort.

A

I agree

B

Phone for verbal consent

Confirm and Submit