Yoga Therapeutics Assessment Form | Mythical Healings

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Yoga Teacher Training

First name*

Last name*

Email*

Phone*

Birthday*

Gender

Female

Current or most recent employment*

How did you hear about us?

Yoga Practice Experience

Have you practiced yoga before?*

Yes

No

If yes, how often do you practice?

Styles of yoga practiced (Select all that apply)*

Ashtanga

Vinyasa Flow

Bikram / Hot Yoga

Gentle / Restorative

Hatha

Iyengar

Power Yoga

Kundalini

Viniyoga

Other

If other, please describe

Goals

What do you hope to gain through yoga therapy? Click all that apply and feel free to add under other:

Physical:*

Strength Training

Injury Recovery

Flexibility

Weight Management

Other

If other, please add here:

Mental / Emotional *

Depression

Anxiety

Recovery and/or maintenance

Grief

Changing or improving health/behavior habits

Other

If other, please add here:

Spiritual - please describe*

Yoga practice improvement*

Asanas

Alignment

Pranayama / Breathwork

Meditation

Other

Other:

Challenges

Please describe your chief complaint including the initial onset, the frequency (e.g. all the time, only at night, etc.)*

Please indicate your level of pain/discomfort on a scale of 1-10 (10 being unbearable)*

Are you seeing a health care provider for this complaint? (if yes include name)*

Please describe your discomfort. Is it mainly physical or emotional? If physical - where does it start and end? Is it superficial or deep? Does it feel like muscle, bone, nerve, connective tissue, scar tissue? 1/2*

If emotional, where do you feel it in your body and what does it feel like? 2/2*

What makes your discomfort feel better and what makes it feel worse?*

Health History

Please describe any illnesses or injuries, physical or emotional, including onset, diagnosis and symptoms*

Do you have any digestion issues? (e.g. heartburn, stomach or intestinal pain, diarrhea, constipation, parasites)

How often do you have a bowel movement?

Please list any surgeries or hospitalizations*

Are you currently being treated for any illnesses or injuries?

Structural Issues

Please describe any pain or discomfort you have in your body.*

Please list the areas in your body where you feel pain or discomfort. On a scale from 1-10 give a value to that pain or discomfort.*

Habits and Lifestyle

Please describe your diet. What do you eat on a typical day for breakfast, lunch, dinner and snacks?*

How much water do you drink in a day? Other liquids?*

Please list any medications/supplements you are taking*

What kind of therapies do you use or have you used in the past (e.g. acupuncture, herbal medicine, etc.)*

In a typical 24 hour day, how much time to you spend sitting, standing, walking/exercising, lying down?*

What do you do for work?*

Do you exercise regularly? Please describe*

How do you sleep? How many hours a night and what times?*

Do you have a regular schedule or does it vary? Do you travel a lot?*

Do you drink alcohol? How much/frequency?*

Do you drink caffeine? How much/frequency?*

How much sugar/sweets do you eat in a typical day?*

Do you eat when you are stressed?*

Do you smoke?*

Please describe any past or current recreational drug use

Energetic Considerations

Do you have any breathing issues? Would you like to learn breathing practices to help manage symptoms and mood?*

How is your energy level in general? Which times of day do you have more energy? Which times less? Do you have energy “crashes” and if so at what time of day?*

Are you affected by other people’s energy? Please describe*

Mental Emotional Considerations

Lisa Moore

11731 Carisbrook Lane

Charlotte, NC 28277

info@MythicalHealings.com

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Info on this site is not intended as a substitute for medical care. This website is not intended to diagnose, treat, cure or prevent any disease.

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