Intake Wellness Questionnaire

AYURVEDA

Please checkmark if any of the following applies to you:

By registering as a participant of ZaZen Studio, I agree to the following:

1. I will be participating in meditation and ayurveda sessions, yoga classes, health programs, workshops and other wellness, excercise and healing arts activities (collectively, the "Activities") offered by ZaZen Studio Inc. Suring the COVID-19 pandemic, the "Activities" may be offered online by videos, television, podcasts, apps or other digital media or platforms. All of such offerings, either physical or online, shall be considered "Activities".

2. I agree to assume full responsibility for any risks, injuries or damage, know or unknown, which I might incur as a result of participating in the "Activities" offered by ZaZen Studio Inc. I agree to inform my instructor of any physical limitations, physical discomfort and/or injuries before or during classes, and I take full responsibility for nondisclosure.

3. In further consideration, I knowingly, voluntarily and expressly waive any claim I may have against ZaZen Studio Inc., its owners, its assistance or employees, for injury or damage that I may sustain as a result of participating in the "Activities".

4. I understand that the information and material provided is for educational purposes only. We, at ZaZen Studio Inc., encourage you to use all provided material at your own discretion. If you have any health issue, medical emergency, or a general health question, you should contact your family doctor or other qualified health care provider for consultation, diagnosis and/or treatment, before enrolling in any "Activities" offered by ZaZen Studio Inc.

By signing below I acknowledge that I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Participant's Signature: 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

VIKRUTI SUBDOSHA QUESTIONNAIRE

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.

VATA
MIND
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.
 
BODY
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.
PITTA
MIND
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.
 
BODY
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.
KAPHA
MIND
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.
 
BODY
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.
JOINTS
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
TOTALS

Sending...
Please do not close this window