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Email
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Your email
Name
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Your answer
What are your current challenges / what are you struggling with?
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Your answer
How does this make you feel?
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How important is solving these challenges?
not important
1
2
3
4
5
6
7
8
9
10
very important
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How long have you felt this way?
Days
Weeks
Months
Years
Feels like my whole life
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Why is it important/not important?
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Have you tried to find solutions to your issue? If yes, why do you feel these didn't work?
Your answer
Does your problem stem from an old injury or illness? If yes, explain.
Your answer
Would you say your life would be enriched when you find a solution to these challenges?
Yes
No
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Why do you say this?
Your answer
Have you been formally diagnosed by a doctor with any physical issues or illnesses? What scans or tests have you had to help with this diagnosis?
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How many yoga classes have you done?
0-10
10-20
20-50
50+
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Are you willing to invest time and money in solving this problem?
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Yes - weekly or more sessions for £1000s in total
Yes - twice a month sessions for £100s in total
No
Do you have any of these issues?
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Heart Disease
Shortness of breath or chest pain
High Blood Pressure
Low Blood Pressure
Significant Bone/Joint/Muscle Pain
Tinnitus
Dizziness or fainting
Back pain
Sciatica
Pregnant or breastfeeding
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Please expand on anything you ticked in the last question (unless this has been your focus for this form)
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Any other health issues or trauma (mental or physical) that might affect physical movement?
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Do you have any allergies?
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Are you currently taking any mediation, painkillers or herbal supplements regularly (daily/weekly/monthly)?
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Is there anything else you would like to say?
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