Date of Birth
* Date of Birth
If you had a magic wand, what is one thing you wish you can change about your body, mindset, health, etc?
If "Other," please explain:
What do you think are the causes (e.g., poor diet, stress, lack of exercise, life changes, stress, etc) of your symptoms?
What have you tried in the past (doctors, diets, physical therapists, etc) to help you manage your symptoms? If so, what are some that are particularly effective or ineffective?
Have you had any surgeries? If so, explain the area of surgeries and how long ago they took place.
Describe your current diet. What is your typical breakfast, lunch, dinner, snack, and beverages?
List any medications, supplements, and herbal remedies that you have taken or are currently taking.
Have you had any experiences with yoga? If you answered yes, what style(s) and how frequently?
What is your ideal vision of health and wellness for you?
How did you hear about me and what attracted you to work with me?
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