Well Being Participant Info

Welcome to ASK LIFE CLARITY

Dear Participant

Let us start by expressing our deepest Gratitude for giving us the opportunity to live our Purpose through supporting your Mind and Body to be and act in their Highest Potential.

Please help us serve you better by taking a couple of minutes to tell us about your current health and mind set. We appreciate your time and faith in us and we will make sure we meet and exceed your expectations.

Love & Light

Team Ask Life Clarity

Name*

Email*

Your Phone Number*

Your Local Phone Number*

Address*

Section 1

What is your Prime Motivation to Join our Retreat / Course / Master Programs?*

If you indicated that you are Non Vegetarian, Can you Please describe below the type and frequency of consumption of Non Vegetarian Food.*

Can You Please indicate the Time and the type of Diet that you Consume for Break Fast normally?*

Can You Please indicate the Time and the type of Diet that you Consume for Lunch normally?*

Can You Please indicate the Time and the type of Diet that you Consume in between meals normally?*

Can You Please indicate the Time and the type of Diet that you Consume for Dinner normally?*

Please indicate which option best describes your food likes / dislikes*

	Every Meal!	At least once a Day	At least once a week	Rarely	Never

Fruits
Vegetables
Fried Food
Fast Foods
Rich or Spicy Foods
Sweets / Deserts
Baked Items
Dairy Products (Milk, Cheese ice-cream, yoghurt etc)
Ready to Cook Food

How many Cups / Glasses do you consume in a day?*

How many Cups / Glasses do you consume in a week?*

	More than 3 Cups / Glasses	Less than 3 Cups / Glasses	Don't Drink at All	Too Much to even Count!

Tea
Black Coffee / Expresso
Fresh Fruit Juices
Canned / Packaged Juices
Aerated Drinks
Water
Energy Drinks
Sugar Free Drinks
Alcoholic Beer
Wines
Hard Liquors / Other Alcoholic Drinks

Mostly what do you think influences what and when you Eat?*

	Agree	Somewhat Agree	Not Sure	Somewhat Disagree	Disagree

When Hungry?
From Frustration?
To be Sociable?
From Habit / Conditioning?
Due to Peer Pressure?
To Avoid Acidity / Health Issues?
To be healthy?
For the Taste of Food?
Don't Really Know!

Section 2

Are you suffering with any of the following conditions at present ? (You can choose Multiple Options)*

Please give a brief history of any Surgeries / Operations!*

Please give a brief history of any Mental Trauma in your life. Please try to capture most of your traumatic experiences*

Please give a brief history of any Major illness & Line of Treatments Undertaken (Like Typhoid / Malaria / Dengue / H1N1 / Cancer / Bird Blu / Measles or others)*

Please give a brief history of Motherhood (If Any) (Conception, Abortion, Child Birth)*

Give us a brief idea of what Medicine/Medications you are consuming*

	3 M/A/N	2 M/N	1 Daily	When needed	Emergency only

Blood Pressure
Oral Contraceptives
Antacids
Diuretics
Insulin / Blood Sugar Pills
Pain Killers
Heart based Pills
Hormonal Pills / Drugs
Cancer Drugs
Steriods
Asprin
Sleeping Pills
Antibiotics
Vitamins & Supplements
Laxatives Chemical
Laxatives Natural
Homeopathy Medicines
Ayurvedic Medicines
Unani Medicines
Anti Allergens

Please give a brief information of the circumstances that made you start the medications?*

Please give a brief information of other treatments that you start when ill (Massages/Acupuncture /TaiChi etc) ?*

Personal Habits *

	Addiction	Habitual	Frequent Use	Causal about it	Curious	Not Used by Choice	Not Tried Yet

Tobacco Smoking
Alcohol
Beer & Wine
Tobacco Chewing
Drugs - Marijuana
Drugs - Cocaine/Heroin/Opium
Drugs - Psychedelic
Drugs - Prescription Pain Killer
Drugs - Prescription Antidepressant
Drugs - Prescription Sleeping Pills
Drugs - Prescription Others

Life Style Habits *

	Abundant	Surplus	Average	Infrequent	Rare	Never

Over night Sleep
Rest & Relaxation
Meditation
Gym / Exercise
Yoga
Walking
Breathing Exercise
Screen Time (Phone laptop etc)
Eating while watching TV/Phone
Holidays (Relaxation)
Holidays (Fun)
Weekend Binge Eating
Weekend Binge Drinking (Alcohol)
Sports / Games
Sitting at a Desk
Standing at Work
Nap during day

Section 3

What symptoms / signals your Body and Mind are giving you about your health?*

	Severe / Frequent	Moderate / Weekly	Mild / Occasionally	Never Occurred

Tiered all the time
Hungry between meals & at night
Fearful / Overwhelmed by people places situations
Magnify relatively smaller issues
Junk Food Consuption
Crave for Sugary Aerated drinks / snacks between meals
Alcohol Consumption
Drink more than 3 Cups of Tea / Coffee
Lack of Energy
Can't work under pressure
Depression
Insomania
Indecisive
Can not Concentrate
Poor Memory
Worry Frequently
Low Self Image
Insecurity
Highly emotional
Moody
Sensitive / can cry easily
Fits of Anger
Headaches / Migraines
Sleepy during day
Drowsy after meals
Can not get started in the morning
Eat when nervous
Fatigue relived by eating
Fatigue relived by Sleeping / Resting
Allergies
Get shaky inside when Hungry
Suicidal thoughts / tendencies
Bad dreams / nightmares
Cold sweaty hands / feet
Hot Flushes at Night
Hot Flushes during the Day
Trembling Hands
Bruise easily
Bleeding Gums
Tooth decay / enable thinning
Disturbed motor-control
Losing Balance on sudden movement
Muscle twitching
Muscular cramps / Stiffness
Lower Back Pain
Shoulder Blades Pain
Full Back Pain
Pain in Buttocks area
Leg Cramps / Restlessness
Phobias
Frequent Urination
Nervousness / Cramps in Stomach
Asthma Hay Fever Rashes
Irritable before meals
Feel Faint if Meal is delayed
Bored
Palpitations
Ulcers / Gastric / Chronic Acidity
Indigestion / Bloating
Blurred Vison
Dizziness / Giddiness / Light Headedness
Aware of Breathing Heavily
Excessive Sweating
Excessive Thirst
Drastic weight Change
Nausea
Anxiety / Panic Attacks
Excessive focus on cleanliness
Fear of germs / infection
When things are not organised creates scarcity

Thank You :)

We sincerely appreciate your time and efforts and we are committed to your well being and growth. We will take your inputs into consideration while supporting you to heal rejuvenate and take charge of Your Life!

If you have any comments or concerns please Contact:

Team Ask Life Clarity | This email address is being protected from spambots. You need JavaScript enabled to view it.

'ASK Life Clarity | Well Being | Participant Information

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