Yoga and Meditation Intake Questionnaire Yoga and Meditation Intake Questionnaire Please fill out this Form at least 24 hours before your first class. Your data will be treated confidentially. This form is voluntary. It helps me to teach you properly and to help you get the most out of your session. All information is not mandatory to attend.Personal DataName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Birthday Children?NoYesOccupation About Your PracticeHow did you hear about Sacred Becoming with Xandra O'Neill?What is your primary reason for coming today? (feel free to include other reasons why you’ve chosen to practice yoga)*What do you hope to gain from this meditation and yoga session?*Any previous treatments or methods regarding this condition/ goal?Have you practiced yoga before?*YesNoHow would you describe your previous and current experiences with yoga?Is there anything that has felt like it was missing from previous yoga experiences? If so, what are they?What is your favorite yoga pose and why?Why do you want to practice yoga?What words come to mind when you think of yoga?What other forms of movement are part of your lifestyle and how often?Do you have a meditation practice?NoYesHow would you describe your previous and current experiences with meditation? What forms of meditation have your practiced?Is there anything that has felt like it was missing from previous meditation experiences? If so, what are they?LifestyleOn a scale of 1-10, (1 being minimal and 10 being unbearable) how would you rate your level of stress right now?Please enter a number from 1 to 10.On a scale of 1-10 (1 being minimal and 10 being unbearable) how would you rate your level of stress on weekdays in general?Please enter a number from 1 to 10.On a scale of 1-10 (1 being minimal and 10 being unbearable) how would you rate your level of stress on the weekends?Please enter a number from 1 to 10.Describe the duration and quality of your sleepDo you drink coffee?YesNoDo you drink alcohol?YesNoDo you take any medication?YesNoIf yes to any of the above, please explain how often, and where appropriate, be specific as to what type.Please share any information that you might find helpful for me to know in order to help you reach your goals (difficulty with addictions, stress inducing activities, familial challenges, etc).State of HealthCheck any of the following symptoms, past or present* Back pains Disc problems Gout Scoliosis High blood pressure StrokeTheumatic condition Crohn's disease Neurological conditions Cancer Give a brief history of the conditionPlease list any significant experiences of grief, shock, major disappointment, severe fright, intense and prolonged stress, nervous breakdown, burn-out:Please list any other conditions we should be aware of:*Family HistoryPlease check all that apply Stroke on Mother's side Stroke on Father's side Heart on Mother's side Heart on Father's side Cancer on Mother's side Cancer on Father's side Diabetes on Mother's side Diabetes on Father's side Autoimmune disease on Mother's side Autoimmune disease on Father's side Please share any other conditions on mother or father's side that were not listed abovePlease list any allergies*I understand that: - No medical diagnosis will be given and no promises of cure have been made. - A Yoga practice is no replacement for competent medical care. - That all physical activity entered into is on a voluntary basis only. In case of injury, I take full responsibility. - I am responsible to pay for private sessions I do not attend or those I cancel within less than 48 hours notice. (please sign below) Signature Reset signature Signature locked. Reset to sign again PaymentPayment can be made by cash or check at beginning of session or in advance with credit card/PayPal. Meditation and Yoga Session Quantity Price: $250.00 Quantity This includes a 30 minute meditation session, a 60 minute yoga session, and includes travel. Δ
