On-line Yoga Questionnaire | Chicago Yoga For Children

Child's Name:*

First Last

Date of Birth*

Child's Gender*

Male
Female

Have any family members practiced Yoga?*

Yes
No

If so, how long?

What was the diagnosis of your child at birth?

What are the physical sympthoms of the disability?

Does your child have convulsions? (please describe)

Does your child have a cardiac problem? (please describe)

Does your child have a problem with their spinal column?

Has your child undergone surgery? (please describe, with dates)

Is your child's motor development delayed? (please describe)

How would your describe your child's concentration, attention span, and general awareness?

Would you characterize your child as happy, aggressive, easygoing, enthusiastic, passive, excitable, depressed, introverted, or extroverted?

What other treatemnts or therapies does your child undergo?

What is the diagnosis of your child at present?

Would you like a progress report for them?

Yes
No

How did you hear about Yoga therapy?

What goals do you hope your child will achieve by participating in this program?

What does your child like?

Dislike?

Your Name (required):*

First Last

Your Phone

Your E-mail (required):*

I am the child's:*

Mother
Father
Other

If other, please specify:

Child's Home Address:

Street Address Address Line 2 City State ZIP Code

Child's Main Home Phone:

Child's Emergency Contact Person:

Child's Emergency Contact Person's Phone:

Child's Siblings:

Mothers Name:

Mother's Home Phone:

Mother's Cell Phone:

Mother's Email:

Mother's Home Address

Street Address City State ZIP Code

Father's Name:

First Last

Fathers Home Phone:

Father's Cell Phone:

Father's Email:

Father's Home Address

Street Address City State ZIP Code