Yoga for Parkinson's Intake Form

Name

Address

Phone

Family Members

Support (who helps you)

Hobbies/Activities

Favorite Music

Parkinson's Information

Date of Diagnosis

Specify any Parkinson's issues you are having (medical and movement):

Specify any other issues you are having (medical and movement):

What medications are you currently taking?

How does Parkinson's impact your life?

What did you notice before diagnosis and after diagnosis?

What other doctors/therapists are you working with currently?

What other therapies are you doing currently?

Do you see a movement disorder specialist?

Yes

List what you do on a typical day (morning, afternoon, and evening)

Yoga Information

Who referred you to yoga?

Have you practiced yoga before?

Yes

If so, when?

What type of yoga?

What do you want to get out of a yoga class?

What are your goals?

Additional Information

Any other information you would like to share?

Thanks for submitting!