Thai Yoga TherapyTM Client Intake Form

Please fill out all information as accurately and thoroughly as possible.

Name: ______________________________ Date of Birth: ___________________

Address: _______________________________________

City_______________________ State ___________ Zip _________

WK PHONE: ( ) ____ - ______ HM: ( ) ____-______ CELL ( )____-_____

Email/Web Site: ______________________

Emergency Contact and their relationship to you:

______________________________________ ( )____-_____

Were you referred by anyone? ___________________________________

Have you ever received massage or bodywork before? (If yes, how was it?)

________________________________________________________________________________________________________

Please list any history of important medical conditions, illnesses,injuries,etc

________________________________________________________________________________________________________

Please list any problem areas which are bothering you and describe the sensation. e.g. shoulder/sore, back/tense

etc._____________________________________________________________________________________________________

Please list any medication you are taking prescriptions or non-prescription

________________________________________________________________________________________________________

Do you have any conditions that may require a doctors note?

Y / N

Please list any healing/ stress management techniques you have had experience with e.g. meditation,Yoga, etc

________________________________________________________________________________________________________

I attest that the above is true and accurate to the best of my knowledge

Signature__________________________________________ Date:_____________

Disclaimer: By signing above, I agree that: I understand Thai Yoga TherapyTM is for relaxation purpose. This is not intended to

diagnose medical conditions treat illness or cure injury. I have informed my therapist of my state of health and have

communicated to her clearly any restrictions or limitations I have physically or otherwise. I do not discriminate on the basis of

race, religion, sexual preference or gender.