Initial Consultation Questionnaire

Please answer all questions as best you can. Required fields are shown with *. When you're ready to send us your information, click the "Submit" button at the bottom of the page.

Contact Information

Initial Consultation Questionnaire

1. How did you find out about Octopus Garden?
   
2. Please indicate your intention for practice
   (select from 1-5, where 1 = not a priority, 5 = definitely a priority)

   12345 Flexibility	12345 Enhance Concentration
   12345 Strength	12345 Community (connection, sense of belonging)
   12345 Meditation	12345 Pain Reduction
   12345 Spiritual Development	12345 Alleviate symptoms associated with a medical condition
   12345 Fitness	12345 Emotional balance
   12345 Weight Loss	12345 Curiosity
   12345 Stress Reduction	12345 Recreation/fun
   12345 Rehabilitation

3. How long have you been practicing yoga?
   
4. Health History questions
   (check any of the following that apply)

   Asthma	Nerve pain
   Allergies	Generalized back pain
   Cancer	Neck pain
   Heart disease	Generalized shoulder pain
   Palpitations	Poor circulation
   High blood pressure	Tendonitis
   Low blood pressure	Carpal tunnel
   Thyroid disorders	Major trauma (fall, motor vehicle accident, etc.)
   Diabetes	Seizures
   Stress	IBS (irritable bowel syndrome)
   Depression	PMS
   Anxiety	Insomnia
   Headaches or migraines	Glaucoma
   Muscle pain	Surgery (please list)

5. Constitutional Assessment
   (select from 1-5, where 1 = not accurate, 5 = very accurate)

   ----- Body Type -----
   12345 solid, sturdy	12345 medium, muscular	12345 extremes (ie. tall/short/thin)
   ----- Hair -----
   12345 thick, lustrous	12345 fine, thinning	12345 coarse, dry, wild
   ----- Hands -----
   12345 wide, strong, cool	12345 medium, red, warm	12345 dry, cold, pale
   ----- General feelings of temperature -----
   12345 cold, damp	12345 hot, greasy	12345 cold, dry
   ----- Activity -----
   12345 prefer to relax	12345 assertive	12345 excited, then fatigued
   ----- Eating habits -----
   12345 slow digestion, heavy after meals	12345 strong appetite, can eat large quantities	12345 habits vary, eats quickly
   ----- Sleep Patterns -----
   12345 difficulty falling asleep, awaken easily	12345 sleep soundly, restless with less than 8 hours	12345 sleep deeply for eight or more hours
   ----- Mind -----
   12345 slow, good memory	12345 quick, certain	12345 drifts off easily
   ----- Temperament -----
   12345 calm, difficult to ruffle	12345 easily irritated	12345 changeable, erratic
   ----- Common symptoms -----
   12345 heaviness, general congestion	12345 irritability, acidity	12345 nervousness, exhaustion, jumpiness, gas

6. Please list any physical concerns or injuries.
   

Thank You! Click the "Submit" button to send your answers to Octopus Garden.