Thai Yoga Therapy with Robert Cuozzi
Personal Health Questionnaire

Date Time

Name

Address

Phone (home) Cell e-mail

Age Sex Height Weight

Profession Referred by

Are you presently taking Medications?

Which ones?

Are you presently under the care of a medical doctor or health practitioner?

If yes, for what reasons?

Do you have any restrictions in movement?

Are there any yoga posture(s) or stretches that you fear may be harmful?

Are you pregnant?

Do you wear contact lenses?

A pacemaker?

What physical activities do you regularly partcipate in?

Please detail any recent accidents

Please detail any surgeries

Please circle all that apply: AIDS, allergies, aeortic aneurysm, aterioclerosis, cancer, cervical spine problems, constipation, diarrhea, fractures, heart disease hemophilia, hernia, hypertension, joint problems, mentruation, open wounds/cuts, osteoporosis, phlebitis, previous dislocation, rhematoid arthritis, skin disease, stroke, other

Please note areas of tension and tightness (ie., hamstrings, lower back, neck, chest)

Please note areas of numbness

Please note areas of cramping

Please note areas of pain

Please note ticklish areas

Please “x” out areas where you would rather not be touched: belly, face, feet, toes , other:

Consent & Waiver – I understand that Thai Yoga Therapy is a dynamic, rthytmic practice that stretches, opens and moves energy within the entire body (joints, connective tissue, muscles, energy channels/meridians, etc.) It is understood that the purpose of Thai Yoga Therapy is for relaxation and that it is not meant to diagnose or treat any illness, disease, or any other physical or mental disorder, injury or condition. I have informed my Thai Yoga practitioner about my state of health, and I have transmitted to him any recommendations and restrictions on the part of my medical doctor or therapist insofar as Thai Yoga Therapy is concerned.

Client Signature: Date