Corporate Yoga Muse

New Student History & Lifestyle


Name: Age:

Street Address:

City: State: Zip:

Preferred Phone Number: Secondary Phone Number:

Email Address:

Marital Status:

Any Children?

If Yes, Age(s):

What would you consider your top three health goals?

General Health Information

Height: Weight: Weight one year ago:

Are you happy with your current weight?

Do you have any history of disordered eating patterns?

If yes, please feel free to elaborate a bit:

SECTION II: STUDENT HEALTH

Heart Disease

Shortness of Breath or Chest Pain

Inhaler?

High Blood Pressure

High Cholesterol Level

Significant Bone/Joint/Muscle Pain

Location

Back Pain

Cigarette Smoking

Levels  

Abnormal Resting EKG

Diabetes

Insulin Dependent?

Any other? Please explain:

Are you currently taking any medication(s)?

Type:  

Medical History:

Allergies:

Please list any current or ongoing health issues

Current Supplements:

Food and Diet

Describe typical meal choices:

Breakfast

Mid-morning

Lunch

Afternoon snack

Dinner

Late night snack

Beverages

Percentage of food made at home:

Food cravings:

Lifestyle

How many hours a day/week do you spend driving a car?

Work environment:

How many hours do you sit at a desk?

Does your job require you to walk and move often?

How would you describe the amount of time on your cell phone?

​Do you sit at a computer and if so for how many hours of your work day?

Please feel free to elaborate:

Average hours of sleep per night:

What activities do you like to do to relax?

Stress Levels at Home

Stress Levels at Work

Exercise

What gets you excited about exercise?
Do you feel you are disciplined enough to maintain a fitness route on your own?
Do you feel energized or depleted after your normal exercise regimen?

Type of Exercise

Duration

Times per week

Thank you!

Corporate Yoga Muse https://corporateyogamuse.com
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Document name: New Student History & Lifestyle
Unique Document ID: 0f16090e6cf2cad7dcf00696c807c41a905576a1
Timestamp Audit
2015-11-04 08:46:19 CSTNew Student History & Lifestlye Uploaded by Jen Smith - webmaster@bluezoocreative.com IP 72.221.51.73