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
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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.
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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Do you primarily breath through your nose?
Yes
No
Any other conditions to be addressed?
Previous
Submit Results
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