Ashatya Questionnaire - 2 Week Program

Section A

Full Name *

E-mail Address *

Cell Phone Number *

Other phone number

Mailing Address

What is the date (month/day/year) of your birth? *

Where were you born? *

Where were you rised? *

Where do you live now? *

Are you married? Single? Divorced? *

Do you have children? If so, how many, what ages are they, and do they live with you? If not, would you like children? How many? *

Occupation: *

Past occupations: *

Section B

Have you suffered from physical, emotional, or mental ailments? If yes, please list. *

What is your present diet? (Generally)

Breakfast *

Lunch *

Dinner *

Do you eat meat? If so, how often? If you answered no, when did you stop? *

Do you eat white sugar, white rice, white bread, white pasta, cold drinks? What and how often? If you answered no, when did you stop? *

Do you exercise? What type? How many times in the week? *

Do you spend the majority of your time inside or outside?

How many hours do you sleep in the night? From what hour to what hour? *

Are you taking medications? Have you taken medications in the past? Please specify and provide information of the illness and approximate dates. *

What is your present daily routine and lifestyle? *

Are Yoga, pranayama, meditation, and nutrition already an integral part of your life? If so, how much have you practiced of each one? What style or type have you practiced? *

Section C

What are the 3 qualities you most like about yourself? *

What are the 3 qualities you least like about yourself? Would you like to change them? *

Do you feel fulfilled in your work? *

When have you felt most fulfilled in life? Doing what? *

What would you love to do in your life? What is your primary goal? *

What are you doing to achieve your goal? *

Do you enjoy spending time alone? How often do you do it? What do you do? *

Please grade yourself in the following areas from 0 to 10. (10 being the highest grade.)

Open mindedness *

Mental clarity *

Independence *

Flexibility *

Desire to improve yourself *

Communication with others *

Level of positivity *

Non-judgemental *

Caring for others *

Spiritual Life *

Wanting to unite your will to God’s *

Section D

Do you practice a certain religion, if so which one? *

Do you believe in a Divine Intelligence? *

What is your connection with this Divine Intelligence? *

What do you believe happens after death? *

What do you believe is the truth of life? For what reason are we born? To do what? To achieve what? *

What questions do you mainly find yourself searching for the answers to? *

Section E

From what date would you like to attend a 2-week personal retreat with us?

Would you like to arrange for a taxi to pick you up at the airport ($100 - $120 USD)?

Yes

Do you speak Spanish?

Yes

Please tell us how you found Ashatya. If you found us through the internet, what search engine, keywords or link did you use? *

Is there anything else that you would like us to know? *