YOGA THERAPY QUESTIONNAIRE FORM

General Information

  • Contact Informatin

  • Physical Detail

  • Medical History

    About Parents (Have they been suffering with)

    Section

    Cardiac Problem

  • Low or High Blood Pressure

  • Asthma

  • Diabetes

  • Cancer

  • Hypo or Hyper Thyroidism

  • Cancer

  • Hypo or Hyper Thyroidism

  • Adrenal Fatigue

  • Kidney failure

  • Migraines

  • Digestive Disorders

  • Any other major health problem

  • About You

    Previous Illness (in last 10 years but doesn’t exist now)

  • Any major surgery

  • Any accident

  • Current illness

  • List of any current Medications, give the names of medicines below

  • Lifestyle

  • Eating Habits

  • Main Concerns for Taking Yoga Therapy