Health Counseling

Intake Form/Client Profile Name: * Email: * Phone: * Age: * Gender: * Female Male Current Health Status: * Injuries / Physical Limitations: * Are you taking? * Prescriptions Herbs Over-The-Counter Medications Other Medical History: * List any surgeries, illnesses, history of serious illness here Do you smoke? Yes, more than one pack a day Yes, less than one pack a day No Do you drink alcohol? Yes, less than a few a week Yes, more than a few a week No Provide a typical day of Meals: Breakfast Lunch Dinner Experienced with Yoga? * Yes No Other forms of fitness/exercise you participate in: * What are your goals for health and wellness? * Type the characters you see in the picture below

Thank you so much!  I look forward to being of service and guiding you to better health and wellness!

Namaste,

Mindi