Burnout Questionnaire

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Home
Yoga Therapy
SERVICES
CLASS SCHEDULE
- CLASS SIGN UP
Book
BLOG
- EAT
- MOVE
- LIVE
- MEDIA
ABOUT
CONTACT
- OM VIP
- FREE CONSULT
COVID 19 Screening Form
Cupping Therapy Waiver
Student Waiver

BURNOUT QUESTIONNAIRE

Burnout is defined as a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands. As the stress continues, you begin to lose the interest and motivation that led you to take on a certain role in the first place.

BURNOUT

* Indicates required field

Have you ever experienced BURNOUT *

Yes No Maybe

Was the BURNOUT? *

Job Related Life Related

Please specify: *

Check ALL Symptoms that apply to your personal experience with BURNOUT: *

Anxiety Depression Feeling Overwhelmed, Excessive Stress Sadness, Anger, Irritability Lack of Creativity or Purpose Fatigue Headaches Difficulty Sleeping Alcohol or Other Substance Abuse Poor Health or Vulnerability to Illness/Health Issues

Did you seek medical attention or advice? *

Yes No

What type of Healthcare Professional to you see? *

Primary Care Physican Psychologist Therapist Holistic Practitioner N/A

Did your doctor prescribe you medication? *

Yes No

If yes, please specify: *

YOGA

Do you practice Yoga? *

Yes No

Did Yoga help relieve your burnout symptoms? *

Yes No N/A

Do you Meditate? *

Yes No

Did Meditation help relieve your burnout symptoms? *

Yes No N/A

Do you Journal? *

Yes No

Did Journaling help relieve your burnout symptoms? *

Yes No N/A

Do you practice Self Care *

Yes No

Please describe you Self Care Routine(s) *

Did you Self Care Routine help relieve your burnout symptoms? *

Yes No N/A

PERSONAL INFORMATION

Gender *

Male Female

Age *

18-25 26-35 36-45 46-55 56-65 Over 65

Employment *

Unemployed Part-time Full-time Self-employed

Occupation *

Optional Sign-up to receive information on the Benefits of Yoga for Burnout

Name *

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Last

Email *

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