Lisa Fabry Nutrition & Yoga Therapy
Date of birth
Phone number (inc country and area code)
Medical practitioner name and address
Do you have any current medically diagnosed conditions or injuries?
Describe what physical activity you currently do: type, frequency and duration.
Do you have any previous yoga experience? Please describe: type, how long you have been doing it, frequency of practice?
Describe what kind of diet you have eg omnivore, paleo, vegan.
What do you hope to gain from yoga therapy?
Please list all medication you take, including prescribed drugs, over-the-counter medicines and supplements.
For each item, please include: daily dose, reason you are taking it and how long you have been taking it.
Have you ever experienced a hypersensitivity reaction to any medication or remedy?
Do you have any known allergies or sensitivities?