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Tanzania, United Republic Of
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Venezuela, Bolivarian Republic Of
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
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Medical Info
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General Health
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Medications
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Claims / Benefit
Conditions
Feet
Thickened Nails
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Pes Cavus (High Arch)
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Bunions
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Yellow Nails
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Onychocryptosis (Ingrown Nail)
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Corns/Callouses
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Onychauxis
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Itchy or Peeling Skin
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Hallux Valgus
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Onychoptosis (Nail Loss)
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Dry/Cracked Skin
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Overlapping Toes
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Onychomycosis (Nail Fungus)
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Heel Fissures
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Involuted Nails (Curved/Pinched)
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Previous Amputations
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Pes Planus (Flat Feet)
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Male Health
Family History of Prostate Cancer
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History of STD
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History of Back Injury
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Painful Urination
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Nocturnal Urination
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Family History of Prostate Disease
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Energy Level
Low
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Vibrant
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Fatigue
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Clear
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Even
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Dull
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Agitated
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Flat
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High
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Chaotic
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Yoga Goals
Improve Fitness
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Weight Management
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Strength Training
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Increase Well-being
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Flexibility
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Injury Rehabilitation
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Balance
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Stress Relief
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Address Health Issues
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Alternative Therapy
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Other
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Well Being
Hobbies
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Caffeine
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Interests
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Mobility/Walking Aids
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Exercise
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Sports
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Flexibility
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Drinking
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Range of Motion
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Smoking
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Treatment Goals
Support in Healing/Recovery
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Rehabilitation
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Health Advice for Healing
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Improve Well Being
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Improve Symptoms
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Improve Lifestyle
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Pain Relief
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Stress Relief
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Other
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Yoga Interests
Eastern Energy System
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Asana (postures)
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Pranayama (breath work)
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Meditation
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Other
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TMJ (Jaw)
Morning Stiffness
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Grinding
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Ear Ringing
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Ear Stuffiness
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Jaw Pain
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Ear Pressure
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Clicking
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Ear Blockage
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Locking
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Difficulty Opening Jaw
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Difficulty Chewing
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Clenching
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Emotion / Memory
Anxiety Disorder
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Mood Disorder
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Stress
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Substance Use Disorder
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Schizophrenia
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Alzheimer Disease
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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When is your energy highest?
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When is your energy lowest?
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How long do you sleep on average?
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Is your energy constant?
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Acupuncture
Arthritis
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Nerve Pain
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LU/LI (Metal)
Asthma/Allergies
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Female Health
Severe Menstrual Pain
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Hysterectomy
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Last Period
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Number of Pregnancies
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Number of Live Births
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Abnormal PAP test
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Irregular Periods
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Menstrual Period Length
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Menstrual Cramping
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Heavy Bleeding
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Endometriosis
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Infertility
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Currently Pregnant
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Birth Control Method
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Implants
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Fibroids
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PCOS
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Uterine Polyps
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Spotting
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Clots
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Heaviness in Pelvis
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Urinary Incontinence
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Pelvic Organ Prolapse
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Pelvic Floor Injury
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Scar Tissue
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Pelvic Pain
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Vocal History
Otolaryngologist
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Speech Path/Voice Teacher
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Vocal Injury
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Vocal Surgery
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Diagnosis of Vocal Injury
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Currently Performing
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Spleen
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Enlarged Liver
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Yoga
Have Practiced Yoga
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Date of Last Yoga Class
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How Often?
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Anusara
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Ashtanga
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Gentle
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Hatha
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Iyengar
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Kundalini
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Restorative
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Vinyasa/Flow
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Yin
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Vocal Health
Hoarseness
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Complete Loss of Voice
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Loss of Vocal Range
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Difficulty Swallowing
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Difficultly Speaking
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Difficulty Singing
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Pain
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Medications
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Acid Reflux
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Whiplash
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Hydration
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Brain Disorders
Bulimia Nervosa
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Schizophrenia
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Anorexia Nervosa
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Antisocial Personality Disorder
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Claustrophobia
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Sleep Disorder
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ADD
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Depression
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Social Anxiety Disorder
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ADHD
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Generalized Anxiety Disorder
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Autism
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Obsessive Compulsive Disorder
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Asperger Syndrome
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Obsessive Compulsive Personality Disorder
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Bipolar Disorder
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Panic Disorder
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Acute Stress Disorder
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Borderline Personality Disorder
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PTSD
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Agoraphobia
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Headaches
Migraines
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Headaches
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Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Skin
Acne
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Herpes
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Hypersensitive Reaction
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Psoriasis
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Allergic Dermatosis
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Melanoma
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Eczema
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Rash
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Athletes Foot
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Rosacea
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Non-Surgical Scars
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Chemical Burn
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UV Burn
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Surgical Scars
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Hypersensitive Reactions
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Skin Conditions
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Infectious Skin Conditions
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Moles
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Melanoma/Carcinoma
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Skin Irritations
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Athlete's Foot
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Cosmetic Surgery
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Pigmentary Disorder
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Severe Irritability
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Plantar's Wart
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Bruise Easily
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Allergic to Iodine
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Dry Skin
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Oily Skin
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Sensitive Skin
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Sun Damage
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Using ALPHA Hydroxy Acids
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Other Skin
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Cardiovascular
Congenital Heart Defect
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Coronary Artery Disease
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Low Blood Pressure
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Cold Hands
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Cardiovascular Accident
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Blood Pressure
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Acute Coronary Syndrome
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Hyperlipidemia
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Cold Feet
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Swelling
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Pacemaker
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Aneurysm
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Pericarditis
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Heart Disease
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Angina
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Raynaud Disease
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Atherosclerosis
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Myocardial infarction
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Rheumatic Heart Disease
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Congestive Heart Failure
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Cardiac Arrhythmia
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Varicose Veins
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Valve Disorders
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Heart Attack
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Cardiovascular Conditions
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Chronic Ischemic Heart Disease
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Blood Clots
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Lymphedema
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Postural Orthostatic Tachycardia Syndrome
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Phlebitis
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High Blood Pressure
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Chronic Venous Insufficiency
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Other Cardiovascular
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Blood
Thrombosis/Embolism
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Blood Thinner Medication
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Stroke
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Fainting Spells
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Anemia
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Bleeding Disorder
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HIV/AIDS
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High Cholesterol
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Hypercoagulability
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Polycythemia
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Hepatitis
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HIV
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Haemophilia
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Other Blood
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Musculoskeletal
Strain/Sprain
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