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Name
Your answer
Email
Your answer
What are your current challenges / what are you struggling with regarding your digestion? (i.e. IBS Pain, Indigestion, Acid Reflux, Nausea etc).
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Your answer
How does this make you feel?
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Your answer
How important is solving this frustration?
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Not important
1
2
3
4
5
6
7
8
9
10
Very important - would effect my mood / life
Why is it important/not important?
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Your answer
How long have you had this frustration/problem?
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Days
Weeks
Months
Years
My whole life (as far as I know)
Have you tried to find a solution to your problem? Why do you feel these didn't work?
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Your answer
Would you say you have a healthy relationship with food?
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Your answer
Does your problem stem from an old injury or illness? If yes, explain.
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Your answer
Would you say your life would be enriched when you find a solution or a true acceptance of this problem?
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Yes
No
Why do you say this?
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Your answer
Have you been formally diagnosed by a doctor about this problem? Also what scans or tests have you had to help with this diagnosis?
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Your answer
Have you had any of these symptoms? (tick all that apply)
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blood in your poo
diarrhoea for more than 7 days
daily stomach aches or cramps lasting 7 days or longer
Lost weight for no reason
How many yoga classes have you done?
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0-10
10-20
20-50
50+
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
Other:
Is there anything else you would like to say?
Your answer
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