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Email Address
Suburb Pincode
Date Of Birth (dd/mm/yyyy) Residence Phone No.
Organization Designation
Height in ft/inches Weight in Kgs

Personal

What are your Health Challenges ? (Do not miss to write as minor a challenge as Constipation, cold, headache, acidity, water retention, breathlessness, irritability or any other)

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What are your present responsibilities in life?

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Are you worried about your future? What?

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Do you feel the need for some changes in any of the following- concentration, orderliness, negative thoughts, laziness, addiction if any or any other area ?

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How do you react when angry or upset? (Pl. check the correct response) ?

Shout
Keep quiet and bear
Start doing other activity
Ignore
Sleepless
Any other
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How often (frequency) does it happen?

Daily
Weekly
Monthly
Rarely
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What is complete health according to you ?

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Do you need to go on tours? If yes, how often ?

Once a week
Twice a month
Once a month
Once in 2 months
rarely or never
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What is your working time?

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What is your commuting (time spent in travelling for work) time ?

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What changes do you expect from the New Age Yoga class ?

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Other Medical

Hygiene

Appetite [Eating]

Less
Medium
More
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Thirst [glasses of water in a day]

2
3
4
5
6
7
8
9
10 or more
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Urine Color

light yellow
dark yellow
Colorless
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Urine Odour

Normal
Offensive
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Urine frequency

less than 5
more than 5
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Stools Consistency

Normal
Hard
Loose
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Stools Odour

Normal
Offensive
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Stools frequency

less than 3
3 or more
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Sleep Quality

Dreams
Sound
Disturbed
Refreshing
Incomplete
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Sleeping hours From & To [mention if is fixed or varying]

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(For women) M. cycle

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Diet Content

Breakfast Timing

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Lunch Timing

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Snacks Timing

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Dinner Timings

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Breakfast Contents

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Lunch Contents

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Snacks Contents

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Dinner Contents

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Any other meal or related information, then, timing and contents

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How do you eat ?

Eat fast
Chew Well
Just gulp
Read along
Eat because its eating time
Drink water while eating
Eat with gratitude
Eat joyfully
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Do you have any Food Allergy?

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Do you eat outside food? How often ?

Once a month
2
3
4
5 or more number of times a month
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Do you have a habit of munching between the meals?

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Do you feel at low energy at any time during the day?

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Lifestyle

Lifestyle Management constructively contributes to physical and mental health. On a scale of 0 to 10 how do you value it?

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How much are you willing to adapt to a change in your Lifestyle on the scale, in the specified areas - on a scale of 1-10

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Terms & Agreement

Participant Declaration "I am enrolling for the New Age Yoga Class on my own willingness and responsibility. I have been explained and I fully understand the benefits and other effects of the course. I undertake to practise the same, as prescribed from time to time by my instructor, at my own will, risk and discretion. I hereby declare my positive intention willingly to follow the prescribed regimen for my health benefit. I declare that I have informed my instructor of my health conditions for a presciption of regimen suitable for my health. I undertake further to inform my class teacher of any change in my medical condition, if and whnever, it may arise. I declare that I am not pregnant, nor have any illnesses, injuries, surgeries, pre-existing medical condition, nor taking any prescribed medication."

I accept
Dont accept
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Physical Activity

How do you describe your work life

Sedentary Office or Home
Mild activity at work or home
Active, walking and other physical activities
Varying - sometimes sedentary sometimes active
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Do you exercise in any form daily ? How many times ?

Yes everyday or 6 times a week
At least 3-4 times a week
once a week
Never or irregular
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If you exercise, how much time ?

15 min
30 min
45 min
1 hr or more
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Do you walk apart from the exercise daily

Yes daily 30 mts
Sometimes
Never
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If you exercise, what type ?

Swimming
Gymnasium
General Stretches
Yogasana
Walking
Jogging
Sports
Other
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How many minutes can you practice Yogasanas daily

15 min
30 min
45 min
60 min
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What time of the day is most suitable for you to do Yogasanas ? [If more than 1 time suitable tick more] Mention time in Remarks to be specific

Morning
Afternoon
Evening
Late Evening
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When can you go for walk daily ? [Enter multiple if you have choice]

Morning
Afternoon
Evening
Late Evening
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How much is the duration of walk possible for you ?

15 min
30 min
45 min
60 min
0
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Do you have active hobbies ? How much time do you spend on it ? [minutes] Describe your Hobby in Remarks

Yes I follow an active hobby regularly
I have an hobby, sometimes I spend time, less than 30 min in a day
No I dont have any hobby / I am busy, I dont get time to spend on hobby
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Addictions

How many tea or coffee per day?

0
1
2
3
4
5 or more
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Do you smoke? If yes, how many cigarettes in a day ?

0
1
2
3
4-6
7-10
more than 10
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Do you consume alcohol? If yes, how often ?

0
Once a month
2
3
4 or more
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If you consume alcohol, how much in a sitting in pegs/glasses ?

1
2
3
4
5 or more
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Do you consume tobacco ? chew, snuff ...

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Are you addicated to anything apart from this ?

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Follow Up Date (dd/mm/yyyy) Grand Total