Wellness Intake Form

Name *

First

Last

Email *

Phone *

Emergency Name/Contact Info

Date of Birth

Height

Weight

Preferred Pronoun

What experience do you have with yoga, stress management or meditation?

Why are you here? What is your reason for taking class or booking a private session?

What would you most like to gain from this program of wellness? What are your goals and priorities?

Physical Health and Wellness: Please describe any body pain, discomfort or dysfunction. If your body could talk what would it say about it's state of being?

Physical Health and Wellness: Which systems of the body have issues for you?

digestion
respiratory
circulatory
nervous system
immune system
reproductive
endocrine system
eliminatory - urinary, waste, sweat
sight
hearing
skin
muscles
joints

Physical Health and Wellness: In what ways do the issues you checked off above effect you? What are your symptoms?

General Health and Wellness: What do you do to promote relaxation and stress reduction?

General Health and Wellness: What do you do in your life for exercise?

General Health and Wellness: What kind of work are you currently doing or would like to do? Does this work support you financially? Do you enjoy this type of work? Does your work bring you satisfaction? How would you describe your current state of work/life balance?

General Health and Wellness: Describe any major illnesses, surgeries, chronic conditions or accidents that you've had in the last 5 years or the effects of which are still present for you.

General Health and Wellness: Are you currently seeing a health care provider?

yes
no

If yes, what kind of health care provider and why?

General Health and Wellness: Are you taking and precription or non- prescription medications, herbal remedies, vitamins or minerals on a regular basis? What are you taking these for?

General Health and Wellness: Describe your daily routine - usual wake up time, number and type of meals per day, activities, usual bed time, any other details you can provide.

Emotional/Mental Health and Wellness: What is your stress level?

Selected Value: 0

0 = little to no stress, 10 = highly stressed

Emotional/Mental Health and Wellness: Describe the symptoms you experience when you are feeling stressed. Are there specific things that trigger stress for you? What are they?

Emotional/Mental Health and Wellness: What are your most effective strategies for dealing with stress? What are your least effective?

Emotional/Mental Health and Wellness: Do you have close personal relationships with others? Are your personal relationships nurturing and supportive?

Emotional/Mental Health and Wellness: What are the main challenges/issues in your life right now?

Emotional/Mental Health and Wellness: What would you consider to be the main losses you have suffered? Do you feel that these losses have a continuing impact on your daily life? In what ways?

Wisdom/Spiritual Wellness: Do you notice that you are repeatedly encountering the same problems/situations/challenges in life? What are they?

Wisdom/Spiritual Wellness: Are there habits you would like to change? Which habits?

Wisdom/Spiritual Wellness: How are you approaching your life - moment to moment, survival mode, you have and over-arching vision and life plan, opportunist, etc? How is this approach working for you?

Wisdom/Spiritual Wellness: Do you have a strong/defined belief system? How would you describe the spiritual part of your life? Do you consider yourself a spiritual person?

Wisdom/Spiritual Wellness: What do you see as ultimately most important in life? For example: physical health, financial stability, kindness...feel free to answer fully.

Is there any other information you would like to pass onto me?

Website