Intake Form

All personal information will be kept strictly confidential. If you prefer not to answer some questions or to answer them in person, leave those questions blank. Please note that this form cannot be saved and continued -- it must be completed all at once. If you prefer to do it by hand, you can download the form here, then fill it out, scan it, and email it back.

Parts of this intake form are based on the Pancamaya model, a 2500-year-old Indian model of overall wellness and multi-dimensionality of the human system and experience. It provides the framework for applications of Yoga (movement, breathing and meditation).

It is an honor to have this opportunity to learn more about you, and I am looking forward to working with you. ~ Deb Hopkins MPT, C-IAYT

Date:
Name:
Email:
Age:
Occupation:
Relationship status:
If you have children, please list their ages:

Emergency contact person:
Relationship:
Phone:

Referred to yoga therapy by:
Reason for seeking yoga therapy:
Please describe any current or prior experience with yoga:

Physical Activity / Regular Exercise:
Hobbies and Interests:

General health status:
Please list any medical conditions, including mental health conditions that you have been diagnosed with, treated for, or are currently on medications for:
Medications: (prescribed and over the counter)
Past medical history (injuries, significant illnesses, surgeries, chronic or episodic problems):
Please list any physical symptoms of pain, numbness, or tingling over the last year:
Please list any mental health symptoms that you may have had over the past months or weeks:
Describe any body restrictions / limitations with mobility:

Feeling of vitality:
How many hours of sleep do you get each night?
Sleep Onset:
Sleep Continuity:

How is your appetite?
Describe your basic diet:
Describe your digestion:
Any bladder issues (current, past history or periodic)?
Any bowel issues (current, past history or periodic)?

Do you use any of the following?
CaffeineAlcoholTobaccoRecreational drugs

Do you consider yourself a spiritual person? (This may or may not equate to any formal religion.)
How do you express your creativity if at all?
Are you involved in any type of informal or formal learning?
How would you describe your faith or confidence in yourself?
Are you able to speak your truth?
What do you hold dear in life?
Are you able to connect to what you hold dear?
Do you have expectation of and memories of joy in your life?
Are you able to connect with a feeling of joy in your life? If so, how? What helps that happen?

If there is anything I did not ask about that you feel is important for me to know, you can write it in here or share with me in our intake session.