Breath Work/Yoga/Self-Empowerment Questionnaire
DISCLAIMER:  I, John Longinidis, am not a medical doctor and do not claim any of these exercises or methods will cure any breathing pattern disorders, asthma, anxiety, depression, or any other medical conditions.  By agreeing to work together with John Longinidis I do not hold him liable in the event of any physical or mental conditions that are caused from participating in yoga, breath work or meditation
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Email *
Name *
Phone Number *
Were you referred by anyone? If so, who?
Why are you looking for a coach? *
What are you currently challenged by in your life? *
Where do you see yourself in the next 3-5 years?
When you think about that future, what are you afraid of?
If anything was possible, describe your future life and what that would look like?
How committed are you to making these changes and stepping into that life?
Do you ever find yourself out of Breath?  
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If yes, in what situations do you feel breathless?
How invested are you in that future?
Clear selection
If these prices don't feel comfortable for you, what is your level of investment in self-empowerment at the moment?
Why do you think I can help guide you?
Do you have any of the following or have experienced any before?  Please check all that apply
What is your main goal at this time?
Name 3 of your healthy habits:
Name 3 habits you would like to improve:
How would you rate your Nutrition?
Very low
Very High
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How many servings of caffeine do you have per day?  When is your last serving of caffeine generally consumed?
How often do you go to the bathroom daily?  Is it consistent?  Would you describe your stools as runny, loose or solid?
Do you have a Meditation, Breathwork or Journaling practice? (check all)
How many hours per day do you sit?
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How often do you exercise?
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How would you rate your level of stress in your work environment
Very low
Very High
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How would you rate your level of stress at home
Very low
Very High
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List any medications or supplements you take consistently
Describe your average morning (morning routine, food intake, schedule etc)
Describe your average evening  (wind down routine, food intake, technology exposure etc.)
What were you most like as a child? Choose one of the following that best describes you
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