The School Yoga Project (Little Flower Yoga)
Montebello Road Elementary School Pre-Program Survey (2017)

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* 1. Date

Date

Date

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* 2. Student Age

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* 3. Student Grade

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* 4. Do you ever feel challenged by the following?

	YES	NO	Sometimes
Focusing and Concentrating in the Classroom	Focusing and Concentrating in the Classroom YES	Focusing and Concentrating in the Classroom NO	Focusing and Concentrating in the Classroom Sometimes
Being able to deal with anger	Being able to deal with anger YES	Being able to deal with anger NO	Being able to deal with anger Sometimes
Being able to deal with stress	Being able to deal with stress YES	Being able to deal with stress NO	Being able to deal with stress Sometimes
Being confident with people	Being confident with people YES	Being confident with people NO	Being confident with people Sometimes
Being confident with my academic skills	Being confident with my academic skills YES	Being confident with my academic skills NO	Being confident with my academic skills Sometimes
Doing assigned work at school	Doing assigned work at school YES	Doing assigned work at school NO	Doing assigned work at school Sometimes
Completing homework	Completing homework YES	Completing homework NO	Completing homework Sometimes
Getting along with others	Getting along with others YES	Getting along with others NO	Getting along with others Sometimes
Avoiding fights and arguments	Avoiding fights and arguments YES	Avoiding fights and arguments NO	Avoiding fights and arguments Sometimes
Calming down when I am upset	Calming down when I am upset YES	Calming down when I am upset NO	Calming down when I am upset Sometimes
Falling Asleep at night	Falling Asleep at night YES	Falling Asleep at night NO	Falling Asleep at night Sometimes
Making choices	Making choices YES	Making choices NO	Making choices Sometimes
Pausing before reacting	Pausing before reacting YES	Pausing before reacting NO	Pausing before reacting Sometimes

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* 5. Gender (optional)

Boy

Girl

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* 6. Have you ever learned about yoga or mindfulness before the School Yoga Project Program?

Yes

No