Yoga Surveyadmin2022-06-16T04:51:23+00:00 Name Email Phone No. City 1. Do you experience low energy, complain of being fatigued, or feel regularly worn out? Yes No 2. Do you experience any food intolerances, sensitivities, or food allergies? Yes No 3. Does your skin get hives, rashes, itchy, eczema, Rosacea, Acne, Hives, Psoriasis, or other kinds of dermatitis? Yes No 4. Do you experience arthritis, joint pain, or muscle pain? Yes No 5. Do you have any digestive complaints like: constipation, diarrhea, indigestion, heartburn, gas, bloating, burping, acid reflux, GERD, IBS, or IBD? Yes No 6. Do you have any of the following autoimmune disorders - Type 1 Diabetes, Hashimoto’s, Rheumatoid arthritis, Lupus, Celiac, Multiple Sclerosis? Yes No 7. Do you crave sugar, bread, or alcoholic beverages? Yes No 8. Have you ever been bothered by prostatitis, jock itch, vaginal yeast infections, vaginitis, athlete’s foot, ringworm, or other chronic fungal infections of the skin and/or nails? Yes No 9. Have you ever been bothered by prostatitis, jock itch, vaginal yeast infections, vaginitis, athlete’s foot, ringworm, or other chronic fungal infections of the skin and/or nails? Yes No 10. Have you ever taken birth control hormones? Yes No 11. Do you have or have you ever had Post Traumatic Stress Disorder (PTSD)? Yes No 12. Do you have or have you ever had asthma? Yes No 13. Do you have or have you ever had allergies (pollen, pet dander, dust, mold, etc), sinus infections, polyps, chronic post nasal drip? Yes No 14. Do you experience spaciness, brain fog, chronic headaches, migraines, depression, anxiety, and/or ADHD? Yes No 15. Does your weight concern you? Yes No 16. Do you have allergies? Yes No 17. Experiencing digestive problems? Yes No 18. Is your energy level low more often than not? Yes No 19. Are you concerned about your hormone levels or are you experiencing hormonal imbalance? Yes No 20. Do you experience skin issues that concern you? Yes No 21. Have you been diagnosed with an autoimmune disorder? Yes No 22. Do you suffer from depression or anxiety? Yes No 23. How many bowel movements do you have per week? 1-2 Per Week 3-5 Per Week 1-3 every day 4+ per day 24. How many times have you taken antibiotics in your lifetime? If you aren’t sure, what is your best guess? 1-8 9-20 20+ 25. How long were you breastfed for? If you aren’t sure, what is your best guess? never 6 months or less 7-18 months more than 18 months 26. Rate your stress levels on a scale of 1-10 - 1 being calm and peaceful all the time, 10 being completely stressed and highly charged. 1-3 (mostly peaceful, mild and calm) 4-6 (sometimes things bother me) 7-8 (things bother me more than most people) 9-10 (I'm almost always on edge) Please fill in the comment box below. Time is Up! Time's up
