Kids Yoga Therapy
Intake Questionnaire  

Date: _________________________________ 

Caregiver's name(s): ___________________________________________________________________ 

Child's name: __________________________________________________________________________ 

Date of birth: ______________________________ Current age: _______________________________ 

Full term (> 37 weeks) _____ If not, how many weeks gestation: ______________________ 

Weight at birth: _____________________ 

If complications at birth, please list:____________________________________________________ 

If child has diagnoses, please list: ______________________________________________________ 

If medical or physical limitations, please list: __________________________________________ 

__________________________________________________________________________________________ 

If on medication(s), please list: _________________________________________________________ 

If your child has had developmental, achievement, IQ, or other testing, please provide

information along with results: ________________________________________________________ 

__________________________________________________________________________________________ 

Please describe your infant's or child's general behavior: _______________________________ 

__________________________________________________________________________________________ 

What are your main concerns for your child: __________________________________________ 

__________________________________________________________________________________________ 

Additional comments: _________________________________________________________________