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Wellness Assessment - Kaivalyadhama
Welcome to the program on managing Auto-Immune Disorders with Yoga. Kindly fill this form honestly and to the best of your knowledge in order to help us assess your lifestyle and health condition to the fullest.
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Date of form filling
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Name
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Your answer
Mobile Number (with country code)
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Your answer
Email address
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Your answer
Which city do you live?
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Your answer
Gender
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Male
Female
Prefer not to say
Date of Birth
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Occupation
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Your answer
Marital Status
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Single
Married
Divorced
Widow / Widower
How many children do you have? Mention their ages
Your answer
What is your current weight in kgs?
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Your answer
What is your height in inches?
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Your answer
Have you ever enrolled for any Yoga programs before? If yes, please specify the program and it's duration
Your answer
Are you currently practicing Yoga? If yes, since when and how many times in a week do you practice?
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Your answer
Do you engage in any kind of regular exercise program/ sports other than Yoga? If yes, please describe the same
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Your answer
Do you smoke cigarettes / cigars ? If yes, how many cigarettes / cigars in a day?
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Your answer
Do you follow any specific dietary intake plan? How do you feel about your nutritional habits?
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Your answer
Please state your food preferences. You can select multiple options.
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Vegetarian
Vegan
Non Vegetarian
Gluten-free
Spicy foods
Sweets & Desserts
Low calorie diet
Required
Are you suffering from any disease / disorder? If yes, please specify the name of the disease and since how long are you suffering from this? Try to mention as much detail as you can
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Your answer
Do you have any injuries or recent surgery done in past 6 months that may interfere with practicing Asanas / Pranayama? If yes, briefly describe
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Your answer
Do you have any regular pains / aches in joints, back, knee etc? Please describe if yes.
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Your answer
How frequently do you have these pains?
All the time
Once a day
Once in 2 - 3 days
Once a week
Irregular
No pains
Any other health related issues which you would like to share?
Your answer
Mention names of medicines if you are taking currently and for which ailment?
Your answer
How many hours do you sleep at night on average?
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Your answer
How long does it take you to fall asleep ?
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Your answer
How is your overall sleep quality
Poor
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Excellent
Clear selection
Do you get worried / anxious / stressed about things?
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Easily
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Hardly
How often do you have a hearty laugh?
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Very rarely
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Very frequently
Do you get excited about things?
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Easily
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Hardly
How happy are you in life
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Sad
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Very Happy
How would you rate your overall health?
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Poor
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Excellent
Please specify if any of your parents / grand parents on maternal and / or paternal side suffered from major illnesses. Please state who and which diseases.
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Your answer
Any other information you would like to share with us or make any specific requests?
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Your answer
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