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  • About
  • Yoga
    • Classes
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    • Holistic Health Consult
  • 30 Day Live Well Program
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Holistic Assessment

Please ensure you have at least 30 minutes to do this confidential questionnaire.

Step 1 of 7

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  • Personal Information

  • Let's assess your lifestyle!

  • Please list in priority.
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  • Mental Health

  • What are the major causes or factors of your stress?

    (rate all that apply on a scale of 1 (low) to 10 (high)
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  • Physical Health

  • (Indicate type, frequency, time of day and duration) If none, just leave blank.
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  • Work/Student Life

  • Spiritual Health

  • (church, religious group, Meditation, etc.)
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  • Medical History

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  • (e.g. jock itch, athlete’s foot, thrush or vaginal yeast infections)
  • Reproductive Health

  • Females

  • Males

  • (e.g. frequent urination, discomfort during urination)?
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  • Dietary Habits

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