New Client ProfileConfidential Questionnaire Leave this field blank First Name (legal name) Last Name (legal name) Preferred Name/Nickname (optional) Date of Birth Address City, State, Zip Code Mobile Number Email Address Prior Experience Have you practiced meditation before? If yes, please describe your experience and any specific types of meditation you've practiced or apps you have used. What did you like about each one and what did you dislike? Did you achieve the outcome you hoped for? How often do you currently meditate, and what outcomes are you seeking or have experienced from your practice? Do you have any experience with breath work practices? If yes, please describe any specific types of breath work you've practiced or apps you have used and the results. What did you like about each one and what did you dislike? Did you achieve the outcome you hoped for? Have you ever experienced challenges with breathing comfortably? (If yes, please describe the situations or conditions.) Have you practiced Yoga before? If so, please desscribe your experience (frequency, styles, and any specific goals or experiences.) What did you like and dislike? Health and Lifestyle Describe your typical daily schedule or routine. Include any information you feel may be useful for me to know. Do you have any sensitivities, conditions, or challenges related to knee, back, and spine health? (Please describe.) Please list any diagnosed health conditions, chronic symptoms not diagnosed, or important health history. Stress and Emotional Well-being On a scale of 1 to 10, how would you rate your current stress level? (1 = almost no stress, 10 = very stressed on a daily basis) What are your top 3 sources of stress? Please describe how stress adversely impacts you, your relationships, your family, and/or your life? What do you currently do to mananage or deal with stress in you life? Do you experience anxiety or panic attacks? Please describe their frequency and symptoms, how they impact your life, and what you do to manage or prevent them. What have you tried to in the past to address your stress and/or anxiety? What was the result? Additional Information Is there anything else you think would be useful for me to know about you as we start this journey together? Name Name (print) Signature Start drawing Clear Done Start over Signed On: Send
