Complementary Call Personal Assessment Questionnaire Congratulations for taking the first big step towards prioritizing your wellness. Below are very important questions to answer before our first mentoring call. Please complete this form at your earliest convenience and give details with a few minutes of self-realization and meditating over your current status of physical, mental and emotional health. Please start with beginning on specific details on when and how the struggle of health issues began, was it stress, trauma or lifestyle changes, please give ALL details and also your medical diagnosis, medications, therapies you took or are taking currently. Please include a list of your supplements as well. Please share your goals. The more detailed information you share, the more effective our first mentoring call will be. When you have completed the questionnaire click on the SUBMIT button and your answers will be emailed directly to me. Your information will be kept completely confidential. Contact Information Your Name * Your Email * Skype Your Phone * Street City State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Postal Code Questionnaire How did you hear about Dr. Lina Thakar’s Ayurveda wellness mentoring services? Why are you interested in seeking a natural, organic integrative wellness program into your life now? Describe your current status of physical, mental and emotional health. Also list the number of years your struggle with each. What is your profession and your background. Past and current stress levels in the work. What is your family status and background. Past and current stress levels in the family. Please describe your relationship status, struggle if any. Past and current stress levels in the relationship. Please give details and honest answers if you smoke, drink or have/had recreational drugs. Please give details on exercise plan, yoga, mediation etc. What is your immediate desire in improved health and what do you see you would like to achieve? What do you think may be holding you back from reaching your goals now? Include some of the biggest problems/challenges you are facing today. What areas do you need to focus on the most while working on wellness, physical health, stress levels or emotional patterns? Or All? What are the ultimate results you would like to achieve from your mentoring program? Share some fun things about yourself that will give me an idea of who you are as a person. This information will help to define your personal DOSHA, mind body type. Please leave this field empty.