SMMS Yoga Therapy General Consultation Intake Form Open Form New Form Name * First Name Last Name Email * Phone (###) ### #### Time Zone & Preferred Contact Method Gender (Optional) Male Female Other What is your primary reason for seeking a yoga therapy consultation? (Select all that apply) Spiritual growth & meditation practice Physical healing & rehabilitation Emotional or mental well-being support Stress reduction & relaxation Other (please specify): Have you practiced yoga or meditation before? Yes, regularly Yes, occasionally No, I am a beginner What specific challenges or concerns would you like to address? (Briefly describe) If yes, please describe your previous experience and any styles of yoga or meditation you have practiced. Do you have any diagnosed medical conditions? (e.g., chronic pain, heart disease, diabetes, autoimmune disorders) Yes No Have you had any surgeries or injuries in the past? Yes No Do you experience any of the following? (Check all that apply) Chronic pain or stiffness Limited mobility or flexibility Joint issues (arthritis, osteoporosis, etc.) Digestive issues Respiratory concerns (asthma, allergies, etc.) Headaches or migraines Sleep disturbances Anxiety or depression High blood pressure Other (please specify) Are you currently under medical supervision or taking any prescribed medications? Yes (please specify) No Are you currently experiencing any side effects from any prescribed medication? Yes No How would you describe your daily activity level? Sedentary (little or no exercise) Light activity (walking, stretching) Moderate activity (yoga, fitness routine) High activity (athlete, physically demanding work) Do you follow any particular dietary patterns? Vegetarian Vegan Ayurvedic diet No specific diet Other (please specify) How many hours of sleep do you typically get per night? 0-3 3-5 5-8 Greater than 8 Do you experience high levels of stress in your daily life? Rarely Sometimes Often Constantly Are you interested in deepening your meditation or spiritual practice? Yes No Unsure Do you follow any spiritual or philosophical traditions? (Optional) What is your preferred meditation style, if any? Vipassana Mindfulness Mantra meditation Guided meditation Heart Meditation Other (please specify) Do you have any emotional or mental health concerns you would like to address through yoga therapy? Preferred consultation format Video Call (Zoom, Google Meet, etc.) Phone Call Email-Based Guidance Only Preferred days/times for consultations (please indicate time zone) Is there anything else you would like us to know before your consultation? Consent & Agreement * I acknowledge that SMMS yoga therapy consultations are not a substitute for medical treatment, and I agree to consult my healthcare provider before making any major changes to my wellness routine. Yes No Thank you! SMMS Yoga Therapy Cancer Consultation Intake Form Open Form New Form 2 Name * First Name Last Name Email * Phone (###) ### #### Time Zone & Preferred Contact Method Gender (Optional) Male Female Other What is your primary reason for seeking a yoga therapy consultation? (Select all that apply) Spiritual growth & meditation practice Physical healing & rehabilitation Emotional or mental well-being support Stress reduction & relaxation Other (please specify): Have you practiced yoga or meditation before? Yes, regularly Yes, occasionally No, I am a beginner What specific challenges or concerns would you like to address? (Briefly describe) If yes, please describe your previous experience and any styles of yoga or meditation you have practiced. Do you have any diagnosed medical conditions? (e.g., chronic pain, heart disease, diabetes, autoimmune disorders) Yes No Do you have any diagnosed malignancy (cancer)? Yes No Have you had any surgeries or injuries in the past? Yes No Do you experience any of the following? (Check all that apply) Chronic pain or stiffness Limited mobility or flexibility Joint issues (arthritis, osteoporosis, etc.) Digestive issues Respiratory concerns (asthma, allergies, etc.) Headaches or migraines Sleep disturbances Anxiety or depression High blood pressure Other (please specify) Are you currently under medical supervision or taking any prescribed medications? Yes (please specify) No Are you currently facing any side effects from your medications? Yes No How would you describe your daily activity level? Sedentary (little or no exercise) Light activity (walking, stretching) Moderate activity (yoga, fitness routine) High activity (athlete, physically demanding work) Do you follow any particular dietary patterns? Vegetarian Vegan Ayurvedic diet No specific diet Other (please specify) How many hours of sleep do you typically get per night? 0-3 3-5 5-8 Greater than 8 Do you experience high levels of stress in your daily life? Rarely Sometimes Often Constantly Are you interested in deepening your meditation or spiritual practice? Yes No Unsure Do you follow any spiritual or philosophical traditions? (Optional) What is your preferred meditation style, if any? Vipassana Mindfulness Mantra meditation Guided meditation Heart Meditation Other (please specify) Do you have any emotional or mental health concerns you would like to address through yoga therapy? Preferred consultation format Video Call (Zoom, Google Meet, etc.) Phone Call Email-Based Guidance Only Preferred days/times for consultations (please indicate time zone) Is there anything else you would like us to know before your consultation? Consent & Agreement * I acknowledge that SMMS yoga therapy consultations are not a substitute for medical treatment, and I agree to consult my healthcare provider before making any major changes to my wellness routine. Yes No Thank you! Contact Us If you’re interested in collaborating, please provide your information, and we will contact you soon. We look forward to connecting with you. Name * First Name Last Name Email * Message * Thank you!
