[ print this page | close this page | home ] |
|
New Client Form Please share as much or as little about yourself as you would like. If there is a question you would prefer not to answer, simply indicate “NA” for not applicable or no answer – no problem. All personal data will be kept strictly confidential and none of your information will be sold, traded or given away to any third party. A personal meeting will supplement this initial exchange of personal information. All new clients are entitled to a 45 minute introduction and interview to establish goals and to address any concerns you may have. Today’s Date is About you Your name is? How do you prefer to be addressed? Your phone number is? Home Mobile Work Your hard mail address is? Your electronic mail address is? How do you prefer nilambu contacts you? What is your date of birth? What is your physical age? What is your gender? About you and yoga Are you new to Yoga? Yes or No How many years have you studied yoga? What types of yoga have you practiced and where? What is your favorite yoga pose? Why? What is your most challenging yoga pose? Why? Do you currently enjoy a home practice? Do you currently meditate? Are you sensitive to smells and adverse to incense? Are you allergic to wool? What would you most like to achieve through your yoga practice? About you and your body Please circle if any of the following are areas of concern regarding your health Allergy When did your condition(s) start or injury arise? Did a doctor diagnose you? If yes, when? What medications or health supplements are you taking, if any, to manage this condition? What are your symptoms? What events or actions which bring your symptoms on? What do you believe is the underlying cause? Is your condition worse in the morning or at the end of the day? Is there anything else you’d like me to know about this specific condition? Please elaborate on those conditions circled above or describe others not listed: Have you ever been in a car accident or had a traumatic injury? Yes or No If yes, what year and how did it affect your body? Please list any medications, remedies and/or supplements you use
How do you sleep? Do you feel rested?
What type of food do you enjoy?
What other type of exercise do you do?
Do you ever aware of complete silence? If so, when and for how long? |
© 2004 - 2010 nilambu.com PO Box 40811, Washington DC 20016-0811 www.nilambu.com 202 333 8854 |
[ print this page | close this page | home ] |