Yoga Therapy Safety Screening & Contraindications Note

Date/Time: [encounter date and time]

Patient: [name, DOB, and ID/MRN]

Visit Type: [Initial safety screening / Interval re-screen / Change-in-status re-screen] (If re-screen, specify trigger and brief details.)

Setting: [1:1 / Group]; [In-person / Telehealth]

Provider: [name and credentials]

Referral Source: [referral source if applicable]

Reason for Yoga Therapy

[Primary reason for yoga therapy involvement and goals] (1–3 sentences. If re-screen, state the trigger and timing.)

Consent and Preferences

[Service consent documentation] (Document that patient understands proposed yoga practices including movement, breath practices, and relaxation/meditation; had opportunity to ask questions; agrees to proceed; and understands they may pause or stop at any time.)

Touch/Hands-on Assist Consent:

• Touch permitted today: [Yes / No / Conditional]
• Conditions or restrictions: [body regions or types of contact restrictions, or "none"]
• Method of consent: [verbal / written / consent card]
• (Document that prior consent does not imply future consent and may be withdrawn at any time. If consent declined or not obtained, document that no hands-on assists will be used.)

Trauma-informed safety preferences: [cueing preferences, eyes-open preference for balance, specific approaches to avoid] (Include only if relevant to session safety. If patient declines to discuss, note "declined." Omit if not applicable.)

Safety Screening

(Use explicit language: write "denies" or "reports" for each item; do not leave items blank. Do not imply medical clearance; use phrasing such as "screened; no symptoms reported.")

• [denies / reports] chest pain or pressure
• [denies / reports] unusual shortness of breath beyond expected exertion
• [denies / reports] fainting or near-fainting
• [denies / reports] palpitations
• [denies / reports] new or worsening dizziness
• [denies / reports] recent falls or new balance problems
• [denies / reports] new neurologic symptoms (weakness, numbness, severe headache, visual changes)
• [denies / reports] signs of acute illness (fever, severe fatigue beyond baseline)
• [denies / reports] severe or rapidly worsening pain
• [denies / reports] calf pain or swelling (Include when relevant based on history.)

Pregnancy/Postpartum Screening: (Include only if pregnancy known or suspected.)

• Status: [trimester or postpartum timeframe]
• Activity restrictions from obstetric provider: [restrictions if known, or "unknown"]
• [denies / reports] warning signs: dizziness, headache, chest pain, muscle weakness affecting balance, calf swelling/pain, vaginal bleeding or leaking, painful contractions

Screening Disposition: [Proceed / Proceed with precautions / Defer session / Activate emergency response]

[Actions taken, advice given, and patient response] (Required if deferring or escalating. If patient declines recommended escalation, document informed refusal: risks discussed, alternatives offered, patient's decision, and return precautions.)

Screening limitations: [limitations and conservative approach taken] (Include only if screening was limited by cognitive impairment, language barrier, or other constraints.)

Safety-Relevant History

(Include only conditions that change the yoga therapy approach. For each item, state condition, yoga therapy implication, and mitigation. If unknown, write "unknown" with mitigation strategy.)

• Cardiovascular/metabolic conditions: [condition] — [implication for intensity/positioning] — [mitigation]
• Hypertension/orthostatic symptoms: [details] — [implication] — [mitigation]
• Glaucoma/eye disease: [details] — [implication for head-below-heart positions] — [mitigation]
• Osteoporosis/fragility fracture history: [details] — [implication for loading/end-range] — [mitigation]
• Seizure disorder: [details] — [implication] — [mitigation]
• Respiratory conditions: [details] — [implication for breath practices] — [mitigation]
• Neurologic conditions affecting balance/sensation: [details] — [implication] — [mitigation]
• Mental health factors impacting safety: [panic with breath retention / dissociation risk / specific triggers / none] — [implication] — [mitigation]
• Recent surgeries/procedures: [type and date] — [restrictions: ROM/weight-bearing/lifting] — [source: patient report / written protocol] — [implants/devices if relevant]
• Medications with safety implications: [anticoagulants, antihypertensives/diuretics, beta-blockers, sedatives] — [implications: fall/bruise risk, orthostasis, use RPE not HR, balance effects] — [mitigation]
• Functional safety factors: [fall history, assistive device use, vestibular issues, heat intolerance] — [implication] — [mitigation]

(Omit categories that do not apply.)

Observations

(Include only when observations were made. Omit entire section if not performed.)

• Gait and dynamic stability: [observations]
• Sit-to-stand and transfer safety: [observations]
• Range-of-motion limits and guarding: [observations]
• Balance and support needs: [observations]
• Environmental hazards: [hazards identified and addressed]
• Vitals: [values and timing] (Include only if measured.)

Contraindications and Precautions

Overall Participation Decision: [No identified contraindications / Precautions required, proceed with modifications / Contraindicated, defer] (If deferring, state rationale.)

(For each relevant restriction, document: condition, whether contraindication or precaution, specific practices to avoid/modify using operational language, and monitoring plan. Include only applicable domains.)

• [Domain]: [condition] — [Contraindication / Precaution] — [specific practices to avoid/modify] — [monitoring plan]

(Common domains: Dizziness/syncope risk, Pain/acute flare, Post-operative precautions, Glaucoma/inversion restrictions, Hypertension considerations, Balance/fall risk, Heat risk, Respiratory/breath practice limits, Pregnancy-specific restrictions.)

Agreed Safety Plan

Session Modifications: [intensity target via RPE or talk test]; [position limits]; [prop plan: chair, wall, bolsters]; [breath practice limits]; [pacing/rest break plan]

Stop Rules: [symptoms requiring immediate stop: dizziness, chest pain, shortness of breath beyond expected, new neurologic symptoms, severe pain] — Response: [sit/lie down, hydration, reassess, contact pathway, EMS if indicated]

Home Practice: [specific practices, frequency/duration, safety constraints, and stop rules] (If none assigned, state: "No home practice assigned.")

Care Coordination: [Permission to communicate with referring clinician: Yes / No]; [information to share/request]; [follow-up timeframe] (Omit if not applicable.)

Re-screening Schedule: [next planned screening date or trigger]

Signature: [provider signature with credentials and date/time]