Yoga 1-1 via Skype Questionnaire Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact Phone Number*Email Address* SexMaleFemaleNumber of children, if anyDOB of youngest childMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HeightWeightOccupation*Past OccupationsWhat is your motivation for wanting a private yoga session?*Is there an issue you would like to address through yoga?*What else have you tried in addressing this issue, if anything?How much time per week can you dedicate to yoga?*Do you have any experience of practising yoga?*I've tried classes, but do not attend a regular classI've attended a regular class for < 6 monthsI've attended a regular class for > 6 monthsI've been practicing for > 1 yearI have no experienceI teach yoga On a scale of 1 - 10 how would you rate your current stress levels? 1 being low.*What do you think is contributing to your stress levels?Please describe your current state of health*If you have any health concerns, please tell me if you have tried anything else to help treat them.Please give details of any illnesses, accidents or operations you have had.Do you smoke?YesNoOccasionallyHow often to you drink alcohol1-3 times per week1-3 times per month1-6 times per yearI don't drink alcoholWhat forms of exercise do you take?How frequently do you exercise and for how long?Please tick any of the following that you currently suffer from or have suffered from in the past(Check all that apply) Arthritis Back, shoulder or neck pain Other back problems e.g. Scoliosis High blood pressure (excluding pregnancy) Asthma Varicose veins Allergies Stomach or duodenal ulcers Indigestion Diarrhoea, constipation Other digestive disorders (Incl bowel, liver, pancreas, gall bladder disorders) Kidney problems Genito-urinary disorder (including fertility, prostalitis, cystitis) Menstrual problems (PMT, Menopause etc) Diabetes Headaches, migraines Insomnia Cancer Depression Anxiety Mental disorder Epilepsy Rheumatism Damaged joints or muscles in arms or legs Heart disorders Other circulatory disorders Sinusitis Chronic bronchitis or emphysema Grief None Please tick any medications you have taken over the past year(Check all that apply) Laxatives Antibiotics Anti-inflammatories Indigestion tablets Pain killers High blood pressure medication Sleeping pills Tranquilisers Anti-depressants Other medications Please list any other medications herePhoneThis field is for validation purposes and should be left unchanged.
