Ayurveda & Yoga Registration/Waiver


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:



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 me3 = Secondarily or sometimes represents me1= Rarely or doesn't represent me

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



These questions are intended to assess your current life situation, including any recent stresses, illnesses, or life changes. It is most helpful if you answer these questions according to what has been true for you over the past few weeks and months.

1. I've been having difficulty with mental clarity or the ability to focus my attention.
2. I've been feeling overwhelmed, worried, or anxious.
3. My life has been turbulent and chaotic.
4. I've been starting new projects, but have difficulty completing them.
5. I've been having difficulty falling asleep or have been awakening easily.
6. I've been having a hard time making decisions.
7. I've been having trouble following through on commitments I've made.
8. I've been feeling restless if I'm not constantly on the move.
9. I've been acting impulsively or inconsistently.
10. I've been more forgetful than usual.
11. I've been feeling the need to clear my throat, or have a persistent dry cough.
12. I've been getting sore throats, laryngitis, or tonsillitis.
13. I've been having difficulty expressing myself effectively.
14. I've been experiencing gas, cramping, or bloating after meals.
15. My appetite has been inconsistent.
16. Food has been getting caught on its way down to my stomach, or I feel that food is not moving easily through my digestive tract.
17. I've been bothered by constipation.
18. Men: I've been having trouble getting sexually aroused, maintaining erections, or experiencing orgasms.
Women: My menstrual cycle has been uncomfortable or irregular.
19. I've been having trouble with my bladder function.
20. I've been getting light-headed when I get up quickly.
21. My hands and feet have been uncomfortably cold.
22. I've been having heart palpitations.
1. I've been feeling discontented with my life.
2. I've been judgmental and critical of others.
3. I've been feeling jealous of others.
4. I've been expressing anger towards others easily.
5. I've been feeling irritable or impatient.
6. I've been compulsive, with difficulty stopping once I've started a project.
7. I've been strongly opinionated, freely sharing my point of view without being asked.
8. I've been frustrated by other people.
9. I've been feeling the need to out-compete others.
10. I've been ruminating over situations from the past.
11. My eyesight has been deteriorating.
12. I've been having headaches accompanied by Light sensitivity or distorted vision.
13. My eyes have been itchy, sensitive, or watery.
14. I've been having more than two bowel movements per day.
15. My appetite has been excessively strong.
16. I've been getting reflux/heartburn or have an ulcer.
17. I've been feeling that toxins (from food, air, water, alcohol, cigarettes, or drugs) have been building up in my system.
18. I've been diagnosed with some form of liver malady.
19. I've been having abdominal pain after eating fatty meals or have been diagnosed with a gallbladder problem.
20. I've been diagnosed with psoriasis, rosacea, or another inflammatory skin disorder.
21. My skin has been itchy or irritated.
22. I've been diagnosed with skin cancer.
1. I've been dealing with conflict by withdrawing.
2. I've been accumulating clutter in my life.
3. I've been resistant to changing my routine.
4. I've been having difficulty leaving a relationship, job, or situation even though it is no longer nourishing me.
5. My short-term memory has been of concern to me.
6. I've been intending to be more physically active, but have difficulty exercising regularly.
7. I've been eating more out of my emotional rather than nutritional needs.
8. I've been having difficulty getting going in the morning.
9. I have not been confident in my ability to cope with challenges.
10. I've been having a hard time moving beyond the past.
11. My sense of taste or smell has been suppressed.
12. My mouth has been dry.
13. I have had mouth (canker) sores.
14. I've been feeling nauseated after eating.
15. I've been feeling full for an extended time after a meal.
16. After eating, I've been falling asleep or finding it difficult to stay awake.
17. My breathing has been labored or I feel a sense of heaviness in my chest.
18. I have been having episodes of asthma or wheezing.
19. I been having a lot of chest colds/bronchitis or a lingering deep, wet cough.
20. My range of motion is limited more by stiffness in my neck or back than by pain.
21. I've had swelling or stiffness in my kness.
22. My fingers have been swollen, making it difficult for me to grip or wear rings.
1. I've been having joint pain that waxes and wanes in intensity.
2. My joints have been popping or cracking in the morning.
3. I've been having chronic low back or neck pain.
4. My joints have been inflamed and hot.
5. My joints have been painful even at rest.
6. I have joint pain that is relieved with cold.
7. My joints have been stiff in the morning, but improve with activity.
8. My joint pain is characterized by dull, heavy aching.
9. My joints have been swollen.
WEIGHT For each question, choose the answer that best describes your current weight/eating patterns.
1. I am currently
2. Under stress
3. It is easy for me to