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Perfect 10 Lifestyle Lifestyle Evaluation/ Assessment Form
Name________________________________________________________________________
Birthdate_________________________________ Height__________ Weight______________
Phone number_________________________ Email ___________________________________
Address________________________________________________________________________
Do you have any physical constraints/limitations? Please list: __________________________________________________________________________________
Previous surgeries? Please list:__________________________________________________________
Medications? Please list: ______________________________________________________________
Currently taking any supplements? Please list: _____________________________________________
Previous experience with yoga? y/n
If yes, when? How long ago? What style? Please explain: ___________________________________________________________________________________
What are your current goals? (please circle) Weight loss? Improve flexibility? Reduce stress? Relaxation? Meditation? Emotional balance? Create mind/body/spirit/emotional balance? Other? Please explain. ____________________________________________________________________________________
Please describe your attitude in the following categories in 3 words or less:
Mental Clarity _______________________________ Physical Health ____________________________
Spiritual Connectedness ________________________ Emotions _______________________________
Take the following Chakra Personality Test (write Y or N to the left of the number):
1. I generally feel in harmony with the universe.
2. My intuition is quite well-developed.
3. I express myself well in words.
4. I feel emotionally connected with other people.
5. I follow my gut instincts.
6. I am full of vitality and joie de vivre.
7. I love to be in movement and feel my own body.
8. It is easy for me to meditate and find inner peace.
9. I have good concentration.
10. I feel socially confident.
11. I am deeply afraid of loneliness.
12. Eating is one of the great pleasures of life.
13. I know how to enjoy life.
14. I almost never worry.
15. I find it difficult to take the world seriously.
16. I often think about the world and life.
17. I can easily put my thoughts into words.
18. Love is the most important thing in the world.
19. I am at peace within myself and not easily thrown off center.
20. I am a very passionate person.
21. I feel a deep connection with nature.
22. My soul’s home does not lie in this world.
23. I have intense, color-filled dreams.
24. I have many different interests.
25. I have the desire to express myself artistically.
26. I experience feelings mostly in my body.
27. Sex is very important to me.
28. I have a lot of confidence in life and the future.
Do Not Write Below–To Be Determined By Lifestyle Coach:
Lifestyle Coaching suggestions:
1. Physical: Yoga* Cardio *Dancing* Swimming *Fitness *Power Yoga* Restorative Yoga* Massage * Detox * Diet * Thai Chi * Qi Gong_________________________________________________
2. Mental: Meditation * Journaling * Silence * Reading * Listening to audio books * ______________________________________________________________________________
3. Emotional: Cord Cutting * Conscious Breathing * Guided Chakra Meditation * Inner Child Meditations * Practicing Kindness, Mercy and Forgiveness * Hugging ______________________
4. Spiritual: Prayer * Chanting * Playing Music/Singing * Thai Chi * Yoga * Communing with Nature _____________________________________________________________________________
5. Abundance: Decide what you want * Goal Setting * Dream Visualization * Planning and actively pursuing your goals * Dream Boards * Attraction of Dream meditations/visualizations * Belief in yourself meditations ____________________________________________________________
