Yogic Functional Wellness
Coaching program
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What are some of your goals in regards to health/wellness/mindset?
How would you describe your current gut health? ex. bowel movements/metabolism/pain or no pain/ bloating/gas/etc.
Do you presently have any struggles with your health that you would like to share?
What does your daily ingestion of food and drink look like, in general? (types of food/drink)
What do you like to do for exercise/movement? Do you do that regularly?
What are some of your self care practices that you do now?
What are your intentions for the program?
Have you ever practiced yoga before (it is okay if you have not)?
Do you have a yoga mat? (Practices will utilize mats/blocks/blankets) You can get creative if you do not have blocks.
Have you used Zoom before? Please setup your Zoom account if you have not.
Do you have any current injuries or injuries from the past that affect you now?
Are you currently taking any supplements or prescriptions? For how long?
If you are on current prescribed medication, please communicate with your doctor on the supplement regimen we create for you. Agree?
Are you ready to dedicate the next 30-90 days to your self through mindfulness, reflection, yoga/therapeutic movement, holistic supplementation & life style alterations?
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