Name
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First Name
Last Name
Email
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Phone
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Birthday
MM
DD
YYYY
Emergency Contact
First Name
Last Name
Emergency Contact Phone
(###)
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What is your goal for our time together?
List any current & previous health concerns
How long has your current concern been going on
Do you have known triggers from trauma?
Triggers might be yoga poses that feel uncomfortable in your body or types of language that cause your body to have a stress response (flight, fight, freeze, fawn).
Please list any medical conditions, diagnoses, surgeries, accidents, injuries , etc.
Please list any medications you are currently taking, including supplements.
Who else are you currently seeing for your concerns?
Please list the areas of discomfort/tension in your body. Please share the type and degree of discomfort.
What are your favorite physical activities? Do you have a regular exercise routine? Please describe.
Please describe your daily diet and digestive rhythm. What do you typically eat and when? How is your digestion? Do you have daily bowel movements?
Please share your sleep habits. When do you typically go to sleep, wake up? And how rested do you feel?
What is your perceived stress level?
How do you experience anxiety, sadness, or depression?
What life challenges are you currently facing?
What aspect of your life gives you the most joy and happiness?
If you could change one habit, what would it be?
How often would you like to meet?
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Is there anything else you would like to share?
