Name

Email Address

Contact Telephone

Age Group

Preferred Appointment Time

Do you have any yoga experience (if yes, please give a little detail of style, experience etc)

How did you hear about Yoga Therapy Auckland How did you hear about Yoga Therapy Auckland Health Professional Google Search Referring Website Other Referral

Please describe your present state of health.

Please mark any conditions that apply to you Please mark any conditions that apply to you Back or Hip Knee Neck / Shoulder Other Structural Issues (please specify below) Anxiety / Stess Depression / Low Energy Chronic Fatigue / Fibromyalgia Chronic Pain Menstrual Difficulties Fertility Issues Perimenopause / Menopause Symptoms Breathing Issues Hypertension Diabetes Headaches Insomnia Other (please specify in Other Conditions field.)

Other Conditions or Information

Are you currently under the care of any other health practitioner Are you currently under the care of any other health practitioner No GP Specialist Psychotherapist / Psychologist Chiropractor / Osteopath / Physiotherapist Other (please specify)

Other Health Practitioner

Please specify any medication you may be taking.