Client History FormTo make the best of our time together, please complete this form at least 48 hours before your first visit. Name * First Name Last Name Date of Birth * MM DD YYYY Preferred Pronouns * Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Today's Date * MM DD YYYY What is your main reason(s) for seeking yoga therapy? * Are you currently under the care of a physician or other health care provider? * Yes No If yes, for what reason? Please list any diagnosis or diagnoses. Are you released for exercise? * Yes No Do you have any known physical restrictions? * Yes No If yes, please describe. Please select any history with the following * Asthma Allergies Breathing Difficulties Digestive Distress Thyroid Condition Stress Fatigue Autoimmune Disorders Diabetes Cancer High Blood Pressure Low Blood Pressure Coronary Heart Disease Heart Attack Neurological Diagnosis Hernia Headaches Diziness Anxiety Depression Current Pregnancy Menstrual Problems Genitourinary PTS or PTSD Fibromyalgia Sprains/Strains Back Issues Neck Issues Join Issues Sacrum/Pelvis Issues Other None if yes to any of the above, please provide any details, describe any medication associated with diagnosis and any troublesome side effects, if applicable. Please list the type and approximate date(s) of surgeries, major illnesses, chronic conditions, accidents, injuries or other conditions not mentioned above, if applicable. Please describe the amount and quality of your sleep. Do you experience pain during sleep that wakes you up? * Please describe any other medications, vitamins, herbs and reason for taking. Describe any current exercise program. * Please describe any prior experience with yoga and or meditation. * Please outline your personal support system below (friends, family, co-workers, groups, healthcare professionals). * Is there anything else you would like your yoga therapist to know? Thank you!