Vibrant You Participant Questionnaire

Thank you for taking the time to complete this form. While no questions are mandatory, the more information you provide, the better I can assist you. Please know that I operate under HIPPA guidelines as stated on the coaching agreement, so your information remains private and will not be shared.

Name(Required)

First Last

Email(Required)

In a few sentences, tell me why you joined this program.

How old are you?

Have you had lab tests in the last year?

Yes

Has your doctor flagged any labs to watch out for?

Have you been formally diagnosed with any condition or illness? if so, please describe.

Do you have other symptoms or health concerns? If so, please describe.

Do you have a monthly cycle?

Yes

If yes, please state any concerns or difficulties you have with your cycle.

If no, how long have you been without a cycle?

What areas of lifestyle and health do you want/need support in?

Energy Levels

Stress Management

Sleep

Weight Gain/Loss

Exercise Routine

Nutrition

Digestion

Other

If you checked other, please list below.

What, if any supplements are you taking? Please list.

What is your vision for optimal health and wellness? Take some time to consider this. Dream big!

What are 3 specific health goals you'd like to achieve?

Is there anything else you want to tell me?

Thanks for joining the Vibrant You program. I am looking forward to taking this journey with you.

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Stacey Rosenberg, E-RYT 500, YACEP, C-IAYT / Namastacey Yoga, LLC
Group and private yoga classes, workshops, + teacher training in San Francisco and on Zoom.
Virtual Functional Medicine Health Coaching.
Retreats around the globe.
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Vibrant You Participant Questionnaire

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