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Your Place For Yoga Therapy & HealingYoga Therapy • Yoga
Classes • Yoga Teacher Training • HypnosisCranial Sacral Therapy •
Acupuncture • The Feldenkrais Method
1608 29th Ave. North, St. Petersburg, FL 33713(727) 826-4754 •
www.livingroomyoga.biz
LIVING ROOMYOGA
New Student Form/Wellness Questionnaire for Cranial Sacral
Therapy
* Living Room Yoga uses your e-mail address to send out updates
regarding your account status, reminder updates for classes or
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and our weekly studio update newsletter. Your personal information
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electronic communications at any time.
Name:
Address:
City: State: Zip:
Cell Phone: ( ) -
Home Phone: ( ) -
E-Mail*:
Birth Date:
Gender: Male Female
Emergency Contact:
Emergency Contact Relationship:
Emergency Contact Phone: ( ) -
Name of Your Healthcare Provider:
Phone Number of Healthcare Provider: ( ) -
Medications You Are On and What Are They For:
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~ Page 2 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
What is your experience with Cranial Sacral Therapy?
What would you like the outcome of your private appointment to
be?
If your body could talk, what would it say about its state of
being?
How is your diet and digestion?
Where do you have muscle pain or tension?
How would you describe your posture?
What kind of work do you do?
Is your body comfortable at work? Yes No
What kind of exercise do you do, and how often?
What do you do for stress reduction and relaxation? Feel free to
share unhealthy habits as well as healthy ones.
What major surgeries have you had?
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~ Page 3 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
What chronic conditions do you have?
List any accidents or injuries with approximate dates:
What are your main health challenges right now?
To what extent do these challenges restrict your daily life?
Is your schedule: Regular Irregular
Do you have any problems with breathing? Yes No
Do you notice changes in your breath when you become upset or
agitated? Yes No
What happens?
Were you ever a smoker? Yes No
If you are still a smoker, do you want to quit? Yes No
Is your energy level: Low Medium High
Does your energy level fluctuate? Yes No
When do you have dips?
What are your sleep patterns like?
Do you wake up refreshed? Yes No
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~ Page 4 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
Is your stress level: Low Medium High
What triggers your experience of stress?
What do you find most effective for releasing stress?
Do you find yourself getting upset or irritated often? Yes
No
Do you experience anxiety? Yes No
Do you experience depression? Yes No
What emotions do you have difficulty experiencing or
expressing?
Are personal relationships nurturing and supportive? Yes No
Is your career fulfilling? Yes No
What are your main life challenges at present?
What have been your most significant losses?
Do you have friends you can confide in? Yes No
Do you notice that you keep bumping up against the same problems
or situations in life? What are they?
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~ Page 5 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
What habits would you like to change?
Do you have the big picture of your life or do you feel stuck in
the forest just looking at the trees?
How would you describe the spiritual dimension of your life?
What are the most important things in life?
Do you feel like you have a particular mission in this life?
If so, are you fulfilling it?
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~ Page 6 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
Please Check The Goals Below That Are Most Important To
You:Improve Digestion and EliminationImprove PostureImprove Overall
HealthIncrease Body AwarenessImprove BreathingIncrease
EnergyStabilize EnergyImprove SleepHandle Emotions Better
Be Able to Feel Emotions in the BodyGet Less Upset and
IrritatedFeel Less AnxiousFeel Less DepressedFind Greater
Fulfillment in My Work LifeImprove Self EsteemGain a Wider Vision
of LifeGrow SpirituallyHave A Sense of Living Life Fully
Have a Live Experience of the Meaning of Life Have More Control
Over the Direction of My Life See and Change Dysfunctional Behavior
Patterns Have More Satisfying Personal Relationships Improve Diet
and Develop a Healthier Lifestyle Reduce Experience of
Stress/Attain Greater Peace of MindMuscle Strengthening
(Which?)Flexibility (Where?)Joint Stability (Which?)Reduce Pain
(Where?)Change Habits (Which?)Learn Specific Postures or Aspects of
Yoga
How DiD You Hear about us - Please mark only one
Facebook Fan PageReferral by Member:
_______________________Online Info FormHealthcare Provider:
_______________________Driving By/SignLinkedInCrowdSavingsLiving
Room Yoga Car
St. Pete/Tampa Bay TimesTampa Bay Wellness
MagazineTransformations MagazineInternet SearchFlyer in Coffee
Shop: _____________________EversaveLivingSocialOther:
_________________________________Bay News 9
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~ Page 7 ~
Living Room Yoga New Student Form/Wellness Questionnaire for
Cranial Sacral Therapy
Cranial Sacral Therapy Liability Waiver
I am aware that cranial sacral therapy may temporarily increase
my pain or cause me to revisit pains from past injuries on my way
to healing. I understand that during treatment, I may experience a
myriad of sensations including heat or pulsing and that this is an
indication of a therapeutic result. I certify that I have disclosed
all relevant health problems to Living Room Yoga prior to beginning
the program, so the therapist can adjust treatment appropriately. I
agree to take responsibility for my own safety by letting the
occupational therapist know if I experience pain or discomfort. I
acknowledge that the occupational therapist has not and will not
render medical services, including medical diagnosis of my physical
condition. I specifically agree that Living Room Yoga shall not be
liable for any claim, demand, cause of action of any kind
whatsoever for, or on account of death, personal injury, property
damage, or loss of any kind resulting from or related to my use of
equipment or participation in cranial sacral therapy on the
premises of Living Room Yoga. I agree to hold Living Room Yoga
harmless from same.
I have read the above release and waiver of liability and fully
understand its contents. I signify by signing below that I
voluntarily agree to the terms and conditions stated above from
this date forward in all my dealings with Living Room Yoga.
Printed Name
Signature Date
Cancellation Policy Acknowledgement
By signing below, I agree to provide notice of cancellation by
Noon of the previous business day in order not to be charged for
the missed session. Weekend and Monday appointments must be
cancelled by 12:00 noon on the Friday before in order not to be
charged for the appointment.
Printed Name
Signature Date
Name: Address: City: State: Zip: undefined: undefined_2:
undefined_3: undefined_4: undefined_5: undefined_6: EMail: Birth
Date: Gender: OffEmergency Contact: Emergency Contact Relationship:
undefined_7: undefined_8: undefined_9: Name of Your Healthcare
Provider: undefined_10: undefined_11: undefined_12: Medications You
Are On and What Are They For 1: Medications You Are On and What Are
They For 2: Medications You Are On and What Are They For 3:
Medications You Are On and What Are They For 4: Do you have any
problems with breathing: OffDo you notice changes in your breath
when you become upset or agitated: OffWhat happens: Were you ever a
smoker: OffIf you are still a smoker do you want to quit: OffDoes
your energy level fluctuate: OffWhen do you have dips: Do you wake
up refreshed: Offundefined_13: What triggers your experience of
stress: undefined_14: What do you find most effective for releasing
stress: Do you find yourself getting upset or irritated often:
OffDo you experience anxiety: OffDo you experience depression:
Offundefined_15: What emotions do you have difficulty experiencing
or expressing: Are personal relationships nurturing and supportive:
OffIs your career fulfilling: Offundefined_16: What are your main
life challenges at present: undefined_17: What have been your most
significant losses: Do you have friends you can confide in: OffWhat
are they 1: What are they 2: What are they 3: undefined_18: What
habits would you like to change: undefined_19: How would you
describe the spiritual dimension of your life: undefined_20: What
are the most important things in life: undefined_21: Do you feel
like you have a particular mission in this life: If so are you
fulfilling it: Improve Digestion and Elimination: OffImprove
Posture: OffImprove Overall Health: OffIncrease Body Awareness:
OffImprove Breathing: OffIncrease Energy: OffStabilize Energy:
OffImprove Sleep: OffHandle Emotions Better: OffHave a Live
Experience of the Meaning of Life: OffHave More Control Over the
Direction of My Life: OffSee and Change Dysfunctional Behavior
Patterns: OffHave More Satisfying Personal Relationships:
OffImprove Diet and Develop a Healthier Lifestyle: OffReduce
Experience of StressAttain Greater Peace of Mind: OffMuscle
Strengthening Which: OffFlexibility Where: OffJoint Stability
Which: OffReduce Pain Where: OffChange Habits Which: OffLearn
Specific Postures or Aspects of Yoga: OffBe Able to Feel Emotions
in the Body: OffGet Less Upset and Irritated: OffFeel Less Anxious:
OffFeel Less Depressed: OffFind Greater Fulfillment in My Work
Life: OffImprove Self Esteem: OffGain a Wider Vision of Life:
OffGrow Spiritually: OffHave A Sense of Living Life Fully:
Offundefined_22: undefined_23: 1: 2: undefined_24: undefined_25:
undefined_26: undefined_27: undefined_28: undefined_29: Printed
Name: Date: Printed Name_2: Date_2: What chronic conditions do you
have: What chronic conditions do you have2: List any accidents or
injuries with approximate dates: List any accidents or injuries
with approximate dates2: What are your main health challenges right
now: What are your main health challenges right now2: To what
extent do these challenges restrict your daily life: To what extent
do these challenges restrict your daily life2: Schedule: OffEnergy
Level: OffWhat are your sleep patterns like: What are your sleep
patterns like2: Stress Level: Offat the trees: at the trees2: How
Heard: OffWhat would you like the outcome of your private
appointment to be: What would you like the outcome of your private
appointment to be2: If your body could talk what would it say about
its state of being: If your body could talk what would it say about
its state of being2: How is your diet and digestion: Where do you
have muscle pain or tension: Where do you have muscle pain or
tension2: How would you describe your posture: How would you
describe your posture2: What kind of work do you do: What kind of
work do you do2: Is your body comfortable at work: OffWhat kind of
exercise do you do and how often: What kind of exercise do you do
and how often2: What major surgeries have you had: What do you do
for stress reduction and relaxation: What do you do for stress
reduction and relaxation2: What major surgeries have you had2: What
is your experience with Cranial Sacral Therapy: What is your
experience with Cranial Sacral Therapy2: