Name:
Date:
E-mail address:
Address (optional):
Are you a vegetarian?
- yes
- no
- partial
Are you spiritual/holistic in your outlook on life?
- yes
- no
- not really
Your phone number (optional):
How do you regard yourself? (mark as many attributes as you like)
- teacher
- student
- artist
- altruist
- questioner
- parent
- protector
- giver
- taker
- curious
- self-motivated
- thinker
- understanding
- liberal
- practical
- leader
- follower
- serious
- difficult
- forgiving
- selfish
- careful
- carefree
- friendly
- cultural
- private
- secretive
- dependable
- mechanical
- self-starter
- decisive
- doubter
- sincere
- procrastinator
- professional
- generous
- tight-fisted
- jolly
- lucky
- critical
.
.
.
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
concept:
Once you start on the course, continuity is important. Can you commit
half hour per day for your well-being?
- yes
- no
Please select ONE concept you feel at home naturally
- Mountain
- Stream
- Tree
- Unity
- Duality
Please make a selection for Ayurvedic Health program.
I realize that I am providing this self-assessment volantarily, because I want to improve my spiritual, mental and physical well-being.
Please state what you would like to achieve for yourself.
Your goal:
Be proud that you have taken the first step!
To send the information press this button:
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