Functional Yoga Therapy Intake (Fields marked with a * are required.) Step 1 of 3 33% Basic informationName* First Last Email* Home PhoneDaytime Phone*Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country AgeBirthdate Date Format: MM slash DD slash YYYY QuestionnaireWhat are your current reasons for seeing a yoga therapist?*List your current & previous health conditions? Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates.ConditionDate Press the (+) to add more lines.How long has your current heatlth issue been going on?1 month3 months12 monthsMore than a yearChronicWho else are you currently seeing for your health concerns or general health promotion? How often do you see them?Please list your current medications, including supplements. Press the (+) to add more lines.Please state the areas of discomfort in your body. Try to describe where they are located and type/degree of discomfort.What are your favorite physical movements? Least favorite? Do you have a regular exercise program? Please describe?Where do you hold tension in your body?Briefly describe your typical diet. How is your digestion? Do you have daily bowel movements? Would you describe them as normal, loose or constipated?Briefly state your daily routine. In percentages how much of your day is spent with the following:SittingStandingLiftingDrivingDesk workLying What relieves your pain? What increases your pain? Think about ranges of motion, movements etc.Indicate the pain descriptions that apply most to you.Describe your sleep habits. Do you remember your dreams?Please describe your overall energy level. Does it fluctuate or stay consistent? When are you most energized, least energized?How often do you spend time in nature?How would you describe your breathing patterns?What are your major challenges in personal and work relationships?Are your family/personal relationships amicable or stressful? What are your perceived stress levelsLowModerateHighHow do you typically handle emotional and stressful situations?Are there people in your life that you can talk to or go to for counsel?What's your best technique to handle a stressful situation?What kinds of self healing tools have you found to be most valuable for you?What books or teachers/teachings have you found to be most helpful for you?Do you experience anxiety, sadness or depression? Are there places in your body where these feelings tend to dwell when they come up?What aspects of your life gives you the most joy and pleasure?How do you express yourself creatively? Singing, journaling, writing, dancing, art?Do you have a practice or set of practices to feed yourself spiritually?YesNoPlease describe.What life challenges are your currently facing?Do any of these beliefs apply to you?Do any of these beliefs apply to you: I believe that most of life’s daily challenges can be overcome.I believe that life is hard and I’m just waiting for the next issue to hit me.What do you feel is the ultimate purpose or meaning of your life?Are there times when you feel totally content and at peace with yourself and life? If yes, what does this feel like?If you could change one habit, what would it be?PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.