pel"Sona U:tistory
QUESTIONS IN BOLD ARE
MANDATORY FOR YOUR
SAFETY. Others are suggested to
help us better serve your wellness
needs.
Ifyout" boqy coulq tCllk,whCltwoulq it
sClYClboutyour stCiteof being?
How is your qiet ('metqigestion?
Netme:
Age:
-
Height:
-
Weight: -
Do you hClveClnymuscle pClinot"
tension? Where?
Aqqt"ess:
phone: (H)
(W)
How is your posture?
(C)
whClt kinetof work eto you qo?
EmClil:
whClt isthe n(lme (lnq phone numbet"
of your current heCilthCClt"e
proviqer?
Is yout" boety comfortCible at work?
whqt qa you qo fot exercise?
pleCiselist ClnymeqicCitionsyou Clreon
Clnq whClt they (Ire fot"?
How mCiny time CIweek?
whClt qo you qo fot rel(lxqtion Clnq
stress requction?
whClt woulq you most like to gClin
from yogCl:
List ClnymCiiorsurgeries, chronic
conetitions, or Clcciqentswith the
ClpproximCite qClte:
VVhett etreyour
current heetlth
V'lhqttriggers 'In incre'lse in yoU!" stres
level?
chql/enges?
To whettextent ~o these chqllenges
restt-ictYOW.qqily liFe?
Whqt ~o you fin~ most effectivein
releqsing stt-ess?
Do you get upset Or irrit2ite~often?
15your qqily sche~ule regulqr or
irregular?
Do you experience qepression Or
'Inxiety?
Do you have any ~i(fjculties with
breathing?
Do you notice
'I~ifference
Whqt emotions ~o you have ~i(fjculty
Feeling Or expressing?
in your
breqthingwhen you becomeupsetOr
qgitqte~?
Are personql rel'ltionships nurturing
qn~ supportive?
Were you ever q smoker?
Is your c2ireernurturing Gln~
supportive?
Whqt is yoU!" overql[ energy level?
WhC1t'Ire your mqin liFechq/[enges
right now?
15oUr energy level stqble or v2iriqble?
Whqt 2ireyour sleep pqttems like?
Do you w2ikeup Feeling reFreshe~?When ~o you Feelenergy Auctuqtions?
Whqt is your overql[ stresslevel?
Whqt 'Ire the mqin losses you hqve
suffere~?
Do you hqve close Ftienqsthqt you Cq
conA~e in?
Do you notice thqt you keep bumpin~
up Glgqinstthe Sqme problems or
situ2itions in liFe?
Are tnere IlqDlts you woulct like to
chqnge?
Q Improve overqll heCllth
Q Improve ~iet qnct a~herence tc
healthy lifestyle
Q Re~uce pqin
Do you feel you hqve the big picture of
!ifeqS q whole Or~o you feelstuck in
the forest looking qt the in~ivi~uq!
trees?
How woul~ you ~escribe the spirituql
~imension of your life?
Whqt C\Oyou see as ulttmqtefy
importqnt in life?
Do you feel you hqve q pqrticulqr
mission Or vocqtion in this life qnc\qre
you fulfilling it?
P~tSonal Goals
please check 411thqt qpply qnctprovic\e
~etails where applicqble
Q Muscle strengthening
Q Increqse bo~y awareness
Q Leqrn specific postures or
qspects of yogCl
Q
Q
Q
Q
Q
Q
Q
Q Attqin greClter peqce of mine:!
Q H~nc\le emotions better
Q Able to feel emotions in the
Q
boe:!y
Get less upset qnct irritCltect
Be less Clnxious or ~epresse~
Hqve more sCltisfYingpersonal
relCltionships
Finet gteCltet fulfillment at war
Q
Improve self-esteem
Q
Q
Q
Q GClinq wictetvision of life
Q
Q Muscle stretching an~ flexibility
Improve breqthing
Improve energy level
HClvemore stqble energy level
Improve sleep
Improve breqth aWqreness
Leqrn to ic1entifYstressotS
Re~uce stress
Change
hClbits
Q Better see core pCltterns
Q Have more conttol over the
Q StabilizCltion of joints
etirection of your life
Q Have a richer, eteepet spiritual
life
Q
Q HClvea sense of living life Fully
Q HClvea liveetexperience of the
Improve ctigestion Clnct
eliminCltion
Q Improve posture
meaning of life