Ki to Kaizen Yoga Wellness Survey

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Please take a moment to take a few deep breaths and check into your body & tap into your deeper needs and desires.

The survey will take approximately 3-5 min. to complete.

Share your current habits, struggles & goals - mentally, emotionally and physically.
Notice where you meet resistance and what type of support you need in order to reach your goals.

In Gratitude,
Lara

* As I value your confidentiality, please note your information will not be shared with anyone.

Email *

First & Last Name *

Age Group *

Under 30

31-40

41-50

51-60

61-70

Over 70

How would you rate your current state of health?

EXCELLENT- living on top of the world

GOOD- some days are better than others

FAIR- have to push myself through

POOR- running on fumes and just wanna hit snooze

Taking a holistic look at your mental, emotional and physical health. What are your current health concerns/struggles?

Lack of energy/ living in a fog

Difficulty getting a good nights sleep / waking at night

Too much stress/ feeling overwhelmed

Lack of/Irregular exercise or movement practice

Work/Life balance is outta whack

Digestive Issues- heartburn/reflux, IBS, bloating, constipation, diarrhea

Headaches/Migraines

Feeling disconnected / isolated

Struggle with anxiety and/or depression, mental health issues

Relying too much on food/substances/screens to "destress"

Often feel irritable, high strung & intense

Struggle to get moving, feel unmotivated and lack focus

Never feel properly nourished or found the foods that make me feel vibrant and energized

Pain/Inflammation

Other:

Now take a moment to refine... what is your SINGLE GREATEST body or health challenge? What truly stands out / stands in the way? Please elaborate, what is it that your body needs & wants? We love details around here! *

What do you see as your biggest obstacle to achieving better health?

Time

Motivation

Lack of information/knowledge

Lack of accountability

Lack of support/community

Poor habits

Other:

Clear selection

Which habits would you most like more support with?

Improving digestion

Creating nourishing and healthy meals

Improving sleep quality/patterns

Committing to excercise

Reducing stress

Reducing pain/ inflammation in my body

Increasing energy

Other:

What do you find most challenging during this time of current Covid-19?

I see community support / accountability as a vital part of my self-care routine. (meeting a friend at yoga class, text reminders, insights from other students).

Yes

I've never experienced support around this but would be interested.

Other:

Clear selection

I'm interested in learning how to take my yoga "off the mat" and integrate resiliency throughout my week.

Yes

Clear selection

Please state any "other" additional support you would like on your journey exploring embodied movement & stress resiliency

Send me a copy of my responses.

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