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Consultation Form
Health Consultation
Please fill in the fields so that we have a better picture of your current state of health.
Or you can download the PDF document and you can send it to me at:
yogacomparto@gmail.com
Salutation
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Smoker
Non-Smoker
Please list any medications that you are taking:
Please list any supplements that you are taking:
Please indicate if you have experienced any of the following health conditions:
Blood clotting disorders
Any accidental injury
Respiratory problems
Joints Pain
Headaches
Fainting spells or dizziness
Circulatory or heart problems
Muscle cramping
Ulcers
High blood pressure
Past Surgeries
Numbness or tingling
Back or neck discomfort
Digestive problems
diabetes
Low Blood Pressure
Varicose veins
Insomnia
Please take time to thoroughly explain any of the above checked health conditions:
Do you perform any repetitive movement or sustained position in your work, sport or hobby? If so, what activities?
… and how often?
Do you sit for long hours at a workstation, computer or driving?
What level of stress are you experiencing most recently?
Low
Moderate
High
How is regular Appetite?
Low
How is Bowl movements?
Low
How is sleeping quality?
Average
Daily water Intake?
< 1 Liter
Moderate
Moderate
Good
1 bis 2 Liter
High
High
Excellent
> 2 Liter
How does stress affect your life?
Axiety
Muscle tension
Insomnia
Irritability
Other
What is the primary reason or goal for your Yoga practice?
Have you practiced Yoga (Postures) and Pranayama (Breath Exercise)? And what Yogastyle?
Have you practiced Meditation before? And what types?
Are you familiar with any of these words?
Chakras
Yantra
Kundalini
Hatha
Pranas
RajaYoga
Asthanga
Kriyas
Mantra
Nada
Tantra
Patanjali
Will you please share your opinion/perception on Yoga and Yoga-Practices if you have practiced before?
I the undersigned hereby declare that I have read and understood the medical and health questionnaire, and that all the answers to all the questions by myself: I declare that I have given full and correct information about my past and present medical condition.
Name:
Date:
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