Shaktiveda: Awaken Within Questionnaire

Shaktiveda
Ayurveda with Dr. Cravatta

"Awaken Within" Online Questionnaire

All fields are required

Name (First, Last)	Email address
Address	City
State or Province	Zip or Postal Code
Country	Gender	Male Female
Height/ Weight	Your ideal weight
Phone Number (including area code)	Birth Date (mm/dd/yyyy)

Do you practice any form of meditation?	How often do you practice meditation?

Please describe your current emotional state.	Please describe any blocks that you are aware of that may be influencing your life.

Have you recognized any particular patterns that reoccur?	Do you take any medicine? If so, please list.

Do you smoke? If so, how many per day?	Do you drink alcohol? If so, how much and how often?

Do you sleep well?	What is your main health concern?

Are you in relationship with another person romantically? Please describe.	Why would you like to take this workshop?

If you could wave a magic wand, would you change anything in your life?	Additional comments (optional)
NOTE: Have you forgotten anything? Please double check your form before clicking submit.