Ayurveda & Yoga Registration/Waiver

AYURVEDA & YOGA THERAPY

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

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

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

CHARACTERISTICSVATAPITTAKAPHA
FRAME
WEIGHT
EYES
COMPLEXION
HAIR
JOINTS
SLEEP PATTERN
BODY TEMPERATURE
TEMPERAMENT
UNDER STRESS...
TOTAL FOR SECTION ONE