Name
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First Name
Last Name
Email
*
Your Current Conditon/Aims/Goals
*
Do you have specific areas of concern, discomfort, pain, or any goals that are particularly important to you, whether you're seeking balance and well-being, have experienced recent illness, or hospitalisation, or have a diagnosed condition, or are actively engaged in treatment for your current condition?
Please indicate any of the following conditions/symptoms experienced past and present
It's important to know that in Yoga Therapy, individual constitutions (Prakriti) and imbalances (Vikriti) are taken into account, and these imbalances can vary greatly from one person to another. Although the checklist below covers some of these aspects, it is not complete. Therefore, you may need to provide additional information about your particular condition in the text box above.
Have you previously received an Ayurvedic or Yoga Therapy assessment? If so, do you know your constitutional type/combination?
Vata Constitution and Imbalances:
Pitta Constitution and Imbalances:
Kapha Constitution and Imbalances:
Are you on any medications, herbs, supplements, or plant-based remedies?
Do you use a pacemaker, hearing aid, stoma, artificial joints, surgical pins, or plates, or do you rely on orthotics or wear contact lenses?
Please outline the specific meditation, exercise, sports, yoga, or other practices that are currently a part of your routine. More specifically, what frequency, duration, and the number of days per week you can devote to a yoga practice.
Date
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