This questionnaire helps your chosen yoga instructor teach and guide you within a supportive, therapeutic relationship. Your responses provide insight into your current state of health and balance—physically, energetically, mentally/emotionally, and spiritually.

We’ll use your responses to shape our first consultation and design a personalized yoga plan that meets your needs.

Please keep in mind this is a safe, non-judgmental environment, where kindness toward yourself is always encouraged.

Trauma Sensitive Warning

This questionnaire has been thoughtfully created using a trauma-sensitive framework. Still, some questions about your current state of health may feel triggering. Please respond with only as much detail as feels comfortable and safe for you in this moment. You’re welcome to pause and return later if needed. Additional details can also be shared during your consultation call, at a pace and depth that feel right for you.

Name *

First Name

Last Name

Email *

Age *

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Occupation *

Family Status *

Single

Partnered

Married

Divorced

How many children under 18, elderly , or persons of special needs do you care for in your home? *

1-2

3-5

What would you most like to achieve through yoga therapy? *

It is my intention to create a safe, well-balanced yoga experience for you. Are there other relevant issues that might limit your ability to participate or that you are concerned about? *

What is you level of comfort with holistic practices such as yoga for well-being? *

Not comfortable at all

Somewhat comfortable

I am not comfortable nor uncomfortable. It is simply new for me.

Comfortable

Very Comfortable

It is our intention to co-create a safe, well-balanced yoga experience for you. Are there other relevant issues that might limit your ability to participate or that you are concerned about? *

If yes, please explain

Describe your overall health: *

The following best describes my diet/nutrition: *

Choose one. You can elaborate in your consultation.

Vegetarian with optimized protein and vitamins/minerals

Vegetarian with low protein and vitamins/minerals

Pescatarian

I eat a balanced diet with varying meats as my main protein source

I eat whatever is available without much thought on the nutritional value

Other

The following best describes my digestion: *

Choose on. You can elaborate in your consultation

Very slow with frequent constipation for days

Slow with periodic constipation (stools every 2-3 days)

Rhythmic and optimal for my constitution.

Frequent loose stools associated with digestive imbalances or a diagnosed disorder

Other

I am active for 20+ minutes *

For this purpose, active is defined as moving in a way that increases your heart rate and/or creates strength and flexibility.

0 times a week

1-2 times a week

3-4 times a week

5+ times a week

List activities you participate in on a regular basis. *

List any diagnosed health conditions you are managing. *

Are you currently under a medical professional’s care *

If yes, please explain.

list any prescription or non-prescription medications, herbs, supplements. *

My overall energy level is best described as *

Very low

Low

Stable/optimal

Higher than my healthy norm

Variable

On average I sleep *

3-5 hours a night

5-7 hours a night

8-9 hours a night

10+ hours a night

The quality of my sleep is best described as *

Restless

Light

Sound

Deep

My current level of stress is *

Lower than my normal

Higher than my optimal

Healthy levels for me

Are you experiencing any level of depression or anxiety? *

Please consider diagnosed and undiagnosed experiences.

Yes

Do you experience your personal relastionships as nurturing and supportive? *

Yes

Do you find your career, school experiences to be aligned with your purpose in life? *

Yes

Can you envision yourself changed or transformed through a yoga practice? *

If yes, how do you see yourself? If no, what is the main obstacle to having this new vision of yourself?

What gives you the greatest joy in life? *

Do you have a greater purpose, mission, or vocation in life? *

If yes, pleas describe.

Describe the spiritual and/or religious dimension of your life? *

Feel free to share anything else you think could help us support your overall well-being. *

Thank you!

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