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Health Measures Questionnaire

Health Measures Questionnaire

Please complete this form before your first session so that we can customize the experience to meet your personal goals.

Name

Date

On a scale of 1-10, please rate the following areas. Mark "1" if your experience little or no concerns and mark "10" if this is a high level of concern.

Do you primarily breath through your nose?

Yes

Any other conditions to be addressed?

	1	2	3	4	5	6	7	8	9	10
Stress level
Pain (i.e. low back)
Energy
Sleep
Mood (anxiety)
Cravings
Neck/Shoulder Discomfort
Mental Clarity/Memory
Digestive Issues
Endurance
Blood Pressure
Difficulty Breathing

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