About
Work with Robin
Events
Training
Restoring Prana
STORE
Articles
Blog
Find a Yoga Therapist
Back
About EYT
What is Yoga Therapy?
Faculty, Staff, and Mentors
Robin Rothenberg
Restore Your Prana Mentors
Contact
Back
Work with Robin
Individual Therapy
Online Classes
Robin's Zoom Club
Free EYT Videos and Samples
Recent Interviews & Podcasts
Back
Upcoming events
Back
Essential Low Back Teacher Training
Restore Your Prana Professional Certification Program
EYT Training Opportunities
IAYT Accredited Therapist Training
Part 1: Foundations of Yoga Therapy
Part 2: Applications of Yoga Therapy
Continuing Education
Back
Breathing Lite and Restoring Prana
Benefits of Restoring Prana
Breathing Lite Individual Therapy
Restoring Prana Reviews
Upcoming Restore Your Prana Trainings
Back
Store
Ayurveda
Breathing
Courses with Yoga U Online
IAYT APD
Individual Sessions
Philosophy
Pickleball
Physical Workout
Products
Psycho-emotional
Robin's Zoom Club
Yoga Teacher Education
Yoga Therapist Education
Back
Research
About
About EYT
What is Yoga Therapy?
Faculty, Staff, and Mentors
Robin Rothenberg
Restore Your Prana Mentors
Contact
Work with Robin
Work with Robin
Individual Therapy
Online Classes
Robin's Zoom Club
Free EYT Videos and Samples
Recent Interviews & Podcasts
Events
Upcoming events
Training
Essential Low Back Teacher Training
Restore Your Prana Professional Certification Program
EYT Training Opportunities
IAYT Accredited Therapist Training
Part 1: Foundations of Yoga Therapy
Part 2: Applications of Yoga Therapy
Continuing Education
Restoring Prana
Breathing Lite and Restoring Prana
Benefits of Restoring Prana
Breathing Lite Individual Therapy
Restoring Prana Reviews
Upcoming Restore Your Prana Trainings
STORE
Store
Ayurveda
Breathing
Courses with Yoga U Online
IAYT APD
Individual Sessions
Philosophy
Pickleball
Physical Workout
Products
Psycho-emotional
Robin's Zoom Club
Yoga Teacher Education
Yoga Therapist Education
Articles
Research
Blog
Find a Yoga Therapist
New client intake paperwork
Name
*
First Name
Last Name
Preferred pronouns
Email
*
Address
*
Phone
Date of birth
*
Emergency contact info
*
Please include name and phone number
Primary physician name and phone
*
Occupation
*
Do you have or have you had:
*
High blood pressure
Glaucoma
Osteoporosis
Seizures
Diabetes
Rheumatoid arthritis
Anemia
Heart problems
Asthma
Other breathing problems
Dizziness, vertigo or loss of balance
Unexplained falls or fractures
Hearing difficulty
Hernia/rupture
Unstable/ "trick" joint(s)
Hearing difficulty
Metal implants/artificial joints
Bladder or bowel control problems
Pinched nerves or disc problems
Cancer
Broken bones
Allergies
Blood thinners
Neurological diseases
Headaches
Vision difficulties
Chest pain
Shortness of breath
Night sweats
Joint swelling
Traumatic auto accidents
Major surgeries
Other chronic conditions:
Hysterectomy
Menopausal challenges
Caesarean delivery
Early termination of menses
Do any of the following currently apply?
*
Back problems
Hernia
Joint problems
Epilepsy
Arthritis
Low blood pressure
Hypoglycemia
Chronic fatigue
Anxiety/depression
What is your predominant reason for seeking yoga therapy at this time?
*
Please list any recent surgeries
*
Medications and supplements that you are currently taking
*
Have you experienced other health problems or challenges in your life?
*
Do you experience pain in any part of your body –on occasion, acute or chronic?
*
Tell me a little about your lifestyle? Diet? Exercise program? Do you smoke or drink?
*
How is your breathing?
*
How would you describe your energy levels?
*
Would you describe your overall energy as stable or quite variable?
*
How is your stress level?
*
What types of situations trigger stress or bring it on for you?
*
What are some of the ways you find most effective for releasing stress?
*
Do you awaken from sleep feeling rested? Do you fall asleep easily?
*
How do you have fun in your life?
*
How well do you feel you nourish yourself –with food, love and laughter?
*
How would you describe your state of mind most of the time?
*
How would you describe your spiritual or religious life?
*
What is your experience with Yoga, meditation or other spiritual practices?
*
How often do you practice and is your practice regular?
*
What have you found most beneficial from these practices?
*
What have you found most difficult or challenging?
*
Have you had any previous Yoga injuries? How did they happen?
*
What do you hope to get out of Yoga practice? What is your main goal for Yoga practice?
*
Do you have any other comments/concerns?
*
Thank you!