Kriya Living Health and Wellness Questionnaire
First Name *
Your answer
Last Name
Your answer
Email
Your answer
Subscribe To Kriya Living Newsletter?
Phone
Your answer
Preferred Method of Contact
Age:
Your answer
Relationship Status
City of Residence
Your answer
Children/Ages
Your answer
Pets
Your answer
Occupation
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Hours of Work Per Week
Your answer
Wellness Information
Please List Your Main Wellness Challenges
Your answer
Please List Your Top Wellness Goals
Your answer
At What Point In Your Life Did You Feel Your Best? Why?
Your answer
Any Serious Illnesses, Injuries, Hospitalizations?
Your answer
How Is Your Sleep?
Your answer
How Many Hours?
Your answer
Do You Wake Up At Night?
Your answer
Any Pain, Stiffness or Swelling?
Your answer
How is Your Digestion?
Your answer
Allergies or Sensitivities? Please Explain
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Do You Take Any Supplements or Medications? Please List:
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Any Healers, Helpers, or Therapies With Which You are Involved?
Your answer
What Role Does Sports and Exercise Play in Your Life?
Your answer
Food Information
What Foods Did You Eat Often as a Child?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What Do You Eat Today?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Row 1
Will family/friends be supportive of your desire to make food and/or lifestyle changes?
Your answer
Do You Cook?
Your answer
What Percentage of Your Food is Home Cooked?
Your answer
Where Do You Get the Rest of Your Meals From?
Your answer
Do You Experience Cravings? If So, What From?
Your answer
The Most Important Thing I Can Do to Improve My Family’s Wellness Is:
Your answer
Additional Comments
Anything Else You Would Like to Share?
Your answer
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