Name (please print legibly):
Are you a vegetarian?
Are you spiritual/holistic in your outlook on life?
Your phone number (optional):
- not really
How do you regard yourself? (mark as many attributes as you like)
Please follow a scale of 1 to 10 (1 is low . . . 10 is extremely high)
to rate yourself for the following items.
Your sense of aggression:
Your sense of stress:
Your sense of peacefulness:
On the same scale, show how well you can concentrate on learning a new
Once you start on the course, continuity is important. Can you commit
half hour per day for your well-being?
Please mark ONE concept you feel at home naturally
Please make a selection for Ayurvedic Health program.
I realize that I am providing this self-assessment volantarily, because
I want to improve my family's spiritual, mental and physical well-being.
Please state what you would like to achieve for yourself.
Be proud that you have taken the first step!
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