Body, Breath & Soul Questionnaire


Name *
Do you have any chronic pain, physical limitations, or disabilities?
Are you taking any heavy medication? *
Do you have an active addiction?
Have you had a serious illness or major surgery within the last five years?
Have you experienced trauma, either physical or emotional, recently or in the past? *
Are you currently under medical treatment for any physical or mental conditions?
Are you currently experiencing an emotional or physical crisis? *
Are you currently pregnant or trying to get pregnant?
Do you currently have or have you had any of the following conditions in your lifetime: *
Please indicate other professionals you currently use:
Please indicate any of the following vehicles you use toward personal growth and development: