I'm excited to support you on your breathwork journey!
So that we may hit the ground running in our session, tell me a little about your current situation.
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What do you hope to gain/solve/accomplish together?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are the current roadblocks to achieving your goals?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Please indicate if your job involves excessive:
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Talking\nPhysical Movement"}
How many hours a week do you get physical exercise?
Less than 1 hour1-2 hours2-3 hours3-4 hours4-5 hours5-6 hours6-7 hours7 or more hours{"type":"select","name":"__generic2","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Less than 1 hour\n1-2 hours\n2-3 hours\n3-4 hours\n4-5 hours\n5-6 hours\n6-7 hours\n7 or more hours"}
Do you breathe through your mouth at night? (Do you wake up with a dry mouth?)
NeverSometimesOftenVery Often{"type":"select","name":"__generic3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nSometimes\nOften\nVery Often"}
Please indicate the level of severity of any of the symptoms that you experience (never; mild; moderate; severe)
Coughing or wheezing
NeverMildModerateSevere{"type":"select","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Exercise Induced Asthma or Exercise intolerance
NeverMildModerateSevere{"type":"select","name":"__generic6","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Frequent Cold Hands/Feet
NeverMildModerateSevere{"type":"select","name":"__generic7","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Breathlessness at rest
NeverMildModerateSevere{"type":"select","name":"__generic8","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Frequent sighing or yawning
NeverMildModerateSevere{"type":"select","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Sleep apnea
NeverMildModerateSevere{"type":"select","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Snoring
NeverMildModerateSevere{"type":"select","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Lower back pain
NeverMildModerateSevere{"type":"select","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
High perceived stress or anxiety
NeverMildModerateSevere{"type":"select","name":"__generic15","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Tummy upset/ IBS
NeverMildModerateSevere{"type":"select","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Tiredness despite adequate sleep
NeverMildModerateSevere{"type":"select","name":"__generic18","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Insomnia/Broken Sleep
NeverMildModerateSevere{"type":"select","name":"__generic19","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Poor concentration
NeverMildModerateSevere{"type":"select","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Panic Attacks
NeverMildModerateSevere{"type":"select","name":"__generic21","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Congestions/Colds
NeverMildModerateSevere{"type":"select","name":"__generic22","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Headaches
NeverMildModerateSevere{"type":"select","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Never\nMild\nModerate\nSevere"}
Please indicate the level of severity of any of the following symptoms:
Chest wall pains or tightness in chest
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic24","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Feeling tense
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic25","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Blurred vision
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic26","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Dizzy Spells
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic27","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Fast/Deep breathing
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic29","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Unable to breathe deeply
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic34","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Thumping of the heart
0 = Never1 = Rarely2 = Sometimes3 = Often4 = Very Often{"type":"select","name":"__generic38","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"0 = Never\n1 = Rarely\n2 = Sometimes\n3 = Often\n4 = Very Often"}
Have you had standard lab work completed in the last 12 months?
If yes, do you feel that you got value out of your experience with your healthcare provider?
{"type":"textarea","name":"__generic41","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"I had a basic bloodwork panel completed 6 months."}
Are you interested in connecting with a Medical provider (a trusted partner) who may be able to further assist you with your health journey?
{"type":"text","name":"__generic42","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
