Yoga Therapy Health Assessment


Please read this form over and then fill out those questions which are applicable and feel comfortable. Imagine this as a bridge between you and me. With some extra insight into your experience, some descriptive adjectives for your sensations, we can create a more individualized practice and strategy for your continued healing and growth.

By completing and submitting you are agreeing to the waiver at the bottom of this page.

Please also go to this page and complete the Ayurvedic Assessment then please print, photo, or screen shot of the results and bring it to our session (does not have to be high quality image).

Name *
Date *
Emergency Contact
Emergency Contact
Also please add most common positions at work, ie sitting, standing, or habitual movements.
Include any pain and onset of worst conditions.
(Y/N) Tell me more about what you currently do.
If you have found a routine that worked well for you in the past tell me more. What did you like or not like about it. When do you enjoy moving?
Interrupted? By what? Do you go to sleep and/or wake up in pain? How often?
Click any that affect your health recently or in the past.
How would you describe your immunity?
Do you get sick often?
Surgeries? Medications? Diagnoses?
Specifically, and short term? Broad and long term?
Fears, concerns, questions, hopes, thoughts, all relevant...
Check all that interest you.

Complete Wavier Agreement

(Please read below to best utilize our time together.)


I,_______________________, consent to engage in Yoga therapy for my health problem. I
understand that Yoga Therapeutic methods are based on principles of Yoga, scientific
data, and the experience of Yoga teachers, and they are not, as yet, considered
standard treatments in mainstream medicine or physical therapy. I understand that I
should consult with my physician and obtain consent prior to beginning therapy. I also
understand that I am being advised to consult a physician if I have not done so.

I understand that during Yoga Therapy sessions, I will complete activities designed for my
condition. I understand touching or positioning of my body may be necessary to ensure I
am using the appropriate procedure and I expressly consent to such physical contact. If I
do not wish to be touched, I will initial the consent form here to notify the therapist, so a
joint decision can be made about whether it is appropriate to continue practice with
that limitation (       ).

Yoga therapy is a holistic approach designed to benefit my health-related concern but
that the treatment cannot be guaranteed to be successful. Progress will be monitored by
my therapist over the course of sessions. I understand my Yoga therapist is not a physician
and Yoga therapy is complementary to medical practice, and Yoga therapies are not
licensed by the state.

I understand that information obtained regarding my health or personal history will be
treated as privileged and confidential by my therapist and will not be released to any
person without my express consent, except as required by law. I understand that my
therapist may consult with other Yoga therapists or health professionals about my
progress to help improve my treatment. In so doing, my identity will not be revealed.
Finally, I understand that I am encouraged to ask questions and discuss my progress with
the therapist at all times.

I understand Yoga Therapy includes physical movements as well as an opportunity for
relaxation, stress re-education and relief of muscular tension. As is the case with any
physical activity, the risk of injury, even serious or disabling, is always present and cannot
be entirely eliminated. I understand that I am the best judge of evaluating my own body
pain and physical limitations. If I experience any pain or discomfort, I will listen to my
body, adjust the posture and ask for support from the instructor. I understand that my
Yoga Therapist may assist me in yoga postures, but I will not attempt any postures that
are beyond my physical capability. Yoga is not a substitute for medical attention,
examination, diagnosis or treatment and may not be recommended or safe under
certain medical conditions. I affirm I alone am responsible to decide whether to practice
yoga and participate in therapeutic sessions. I hereby agree to irrevocably release and
waive any claims I may have now or hereafter may have against Jayme Sweere

Thank you so much for filling out these forms and I look forward to seeing you soon.