Waiver of Liability & Terms.

1. I am a participant in Yoga and Ayurveda Therapy. Consultation offered by Therapist Monica Daza during I will receive education and instruction about yoga therapy, diet and nutrition, exercise routine, pranayama, and/or meditation practices.

2. I understand that during sessions, therapist Monica Daza and/or her assistants may demonstrate physically postures, that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I agree to assume full responsibility for any risks, injuries or damages known or unknown, which I may incur because of participation in the session.

3. I agree that neither I nor my heirs, executors, administrators, successors or assigns will hold Monica Daza, her assistants, agents or employees responsible for any injury, accident illness or harm that may befall me orany damage that may occur to my property while I am attending to Ayurveda and Yoga Therapy.

4. I represent and warrant that I am physically fit and I have no medical condition, which would prevent my participation in the Therapy Sessions and/or Consultation.

5. I understand that Ayurveda is not a recognized Medical System in Canada, Only as an alternative health system. Ayurvedic Supplements are not medicine intended to diagnose, treat cure or prevent any disease or disorder in any way or form.

I voluntary agree to the terms and conditions state above.

Signature of the Participant:

Date:

PRAKRUTI DOSHA MIND BODY QUESTIONNAIRE

Name:

Date:

Age:

Gender: M F

This mind-body questionnaire gathers information about your basic nature - the way you were as a child or the basic patterns that have been true most of your life. If you developed an illness in childhood or as an adult, think of how things were for you before that illness.

SCORING: For each characteristic, enter either 5, 3, or I in each box below. Assign the numbers according to this scale:
5 = Most accurately represents me	3 = Secondarily or sometimes represents me	1= Rarely or doesn't represent me

EXAMPLE

Vata

Pitta

Kapha

Note: Please don't repeat the answers in each row. The score or every row should add up to 9

CHARACTERISTICS	VATA	PITTA	KAPHA
FRAME	I am thin, lanky and slender with prominent joints and thin muscles.	I have a medium, symmetrical build with good muscle development	I have a large, round or stocky build. My frame is broad, stout or thick.
WEIGHT	LOW; I may forget to eat or have a tendency to lose weight.	MODERATE; it is easy for me to gain or lose weight if I put my mind to it.	HEAVY; I gain weight easily and have difficulty losing it.
EYES	My eyes are small and active.	I have a penetrating gaze.	I have large pleasant eyes.
COMPLEXION	My skin is dry, rough or thin.	My skin is warm, reddish in color and prone to irritation.	My skin is thick, moist and smooth.
HAIR	My hair is dry, brittle or frizzy.	My hair is fine with a tendency towards early thinning or graying.	I have abundant, thick and oily hair.
JOINTS	My joints are thin and prominent and have a tendency to crack.	My joints are loose and flexible.	My joints are large, well knit and padded.
SLEEP PATTERN	I am a light sleeper with a tendency to awaken easily.	I am a moderately sound sleeper, usually needing less than eight hours to feel rested.	My sleep is deep and long. I tend to awaken slowly in the morning.
BODY TEMPERATURE	My hands and feet are usually cold and I prefer warm environments.	I am usually warm, regardless of the season, and prefer cooler environments.	I am adaptable to most temperatures but do not like cold, wet days.
TEMPERAMENT	I am lively and enthusiastic by nature. I like to change.	I am purposeful and intense. I like to convince.	I am easy going and accepting. I like to support.
UNDER STRESS...	I become anxious and/or worried.	I become irritable and/or aggressive.	I become withdrawn and/or reclusive.
TOTAL FOR SECTION ONE	VATA TOTAL	PITTA TOTAL	KAPHA TOTAL