Wellness Consultation Questionnaire

Client/Student Questionnaire

Please complete to the best of your ability. It's OK if you feel overwhelmed or don't want to answer.
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemaleNon-binaryTransgenderPrefer not to discloseOther
Date of Birth*

MonthDayYear
Time of birth if known
Age
years
How did you hear about Astral House?
Please list friend or "other"
Yoga (online, private, classroom setting)MassageBodywork (i.e. thai yoga massage, craniosacral, manual stretching)Energywork (Reiki, sound therapy, chakra balancing, etc)Other
If "other" please explain
Doctor diagnosed perimenopause or "feel" you are in perimenopauseMenopause (you have not had your period for a year or more)
YesNo
Covid Symptoms (Fever or chills, Cough Shortness of breath or difficulty breathing, Fatigue Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting Diarrhea)?FeverContagious DiseaseBlood Clots/thrombosisPregnancyKidney or Liver ConditionsCancerInflammationUncontrolled HypertensionPainOther
5. If "other" please explain
6. Do you currently have any health imbalances you are aware of that you'd like to share? This can include challenges you are facing beyond those of the physical body. Please list below:
7. Regardless of any diagnosis, what about your condition do you want to address or what qualities will help you find balance? (Examples: reduce pain, recover range of motion, feel heard, improve mood, build strength, feel supported and/or to feel less lonely, to find respite from stress and feel some relaxation, etc.)
8. Have you seen western medical practitioners for your diagnosis/condition/concern and do you feel there have been areas of success or improvement?
9. Have you seen any holistic/alternative healthcare practitioners for your diagnosis/condition/concern and do you feel there have been areas of success or improvement?
10. Why did you choose your specific modality of (Yoga or Reiki or Body⚡Energy work) today?
Reiki or Body⚡Energy Work only?

You may choose to scroll to the bottom and hit submit - or - complete the entire form
VinyasaRestoratieYinHathaBikram/Hot YogaOther
11. What would be your one most desired outcome from yoga/yoga therapy or bodywork?
12. Any other objectives?
MeditationPranayama (breath work)ChantingDeeper yoga studies and practices (e.g. tongue scraping, nedi pots, balancing herbs)Reiki
none (seated only)Moderate (light activity such as walking)High (heavy labor, very active)
YesNo
15a. If so, please state what and since when?
16. What are the typical food you eat on a daily basis?
17. On average, how much soda do you drink a week?
18. On average, how many caffeinated beverages do you consume a day?
YesNo
NeverRarelySometimesOftenVery often
21. Around what time in the evening do you stop eating?
22. Please list any supplements you are currently taking
23. On average, how much water do you drink a day?
24. On average, how many hours of sleep do you get a night?
NeverRarelySometimesOftenVery often
26. What time do you usually go to sleep/wake up?
YesNo
Very poorPoorAverageGoodVery Good
Very poorPoorAverageGoodVery good
Very poorPoorAverageGoodVery good
31. On a scale of 1-10 what would you rate your general level of anxiety/stress?
32. What things cause you notable stress?
YesNo
34. If so, through which means do you tend to do this?
35. When was the last time you decluttered your home/living space?
36. How much time on average, do you spend scrolling on social media?
NeverRarelySometimesOftenVery often
38. If there are any, please list any habits you've been wanting to change?
39. If there are any, please list any habits or lifestyle changes you've been wanting to bring in
40. How many times a week do you exercise/move with some intensity?
41. Which kind(s) of exercise/movement do you do and for how long?
YesNo
43. There is no penalty or judgement here but are there other substances you choose to use outside of what has been mentioned? (Microdosing, cannabis, etc.) Please describe why you take, what frequency, etc.
44. If you are on any medications, please list them.
45. What are some dreams, aspirations, or goals you'd like to manifest?
46. Anything else you want me to know?
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Client/Student Questionnaire

Reiki or Body⚡Energy Work only?