Landing Page | Port Washington Yoga

First name

Last name

Email

What are your goals for your personal wellness plan?

Select all the reasons you practice yoga

Ayurveda Survey Q1. Select the answer/s that best describe your build

Thin

Medium, well-proportioned frame

Ample

Ayurveda Survey Q2. Select the answer/s that best describe your build as a child

Thin

Medium

Plump

Ayurveda Survey Q3. Select the answer/s that best describe your bone structure

Light bones or prominent joints

Medium

Heavy

Ayurveda Survey Q4. Select the answer/s that best describe your ability to gain weight

Difficult to gain

Gain / Lose weight easy when you put your mind to it

Gain easily. Difficult to lose weight.

Ayurveda Survey Q5. Select the answer/s that best describe your eyes

Small, active, dark (any color) eyes

Penetrating light green, grey or amber eyes

Large eyes, thick eyelashes

Ayurveda Survey Q6. Select the answer/s that best describe your skin

Thin, dry skin that chaps easily

Oily skin and hair. Freckles. Moles.

Thick skin, cool, moist

Ayurveda Survey Q7. Select the answer/s that best describe your hair

Thin, dark, coarse, kinky or curly hair

Fine, soft,, fair, reddish, blond, or early grey

Thick, wavy, generally brown, hair

Ayurveda Survey Q8. Select the answer/s that best describe your hair

Tangles easily. Split ends

Gets oily quickly, esp in hot weather

Lustrous

Ayurveda Survey Q9. Select the answer/s that best describe your teeth

Crooked or poorly formed

Moderate size teeth. Bleeding gums.

Large, well formed

Ayurveda Survey Q10. Select the answer/s that best describe your joints

Stiff, crack easy

Loose

Firm and large

Ayurveda Survey Q11. Select the answer/s that best describe your climate preference/s

Warm climate, sunshine, moisture

Cool, well-ventilated space

Anything EXCEPT humid

Ayurveda Survey Q12. Select the answer/s that best describe your appetite

Love snacking. Sometimes eyes are bigger than mouth

Good appetite. Strong, social eater who enjoys spicy food. Get irritable when hungry.

Like sweet and starchy foods. Can skip meals without physical problems.

Ayurveda Survey Q13. Select the answer/s that best describe your bowel movements

Bowel movements irregular, hard, dry or constipated

Easy and regular

Regular, steady, thick, and heavy

Ayurveda Survey Q14. Select the answer/s that best describe your digestion

Sometimes good / sometimes not

Usually good

Fine. Sometimes slow

Ayurveda Survey Q15. Select the answer/s that best describe your disease tendency

Pain

Fever. Inflammation

Edema. Congestion

Ayurveda Survey Q16. Select the answer/s that best describe your disease type

Nervous

Blood and/or liver

Lungs and/or mucous

Ayurveda Survey Q17. Select the answer/s that best describe your feelings towards routines

Dislike routine

Enjoy planning and routine, esp if you create it

Work well with routine

Ayurveda Survey Q18. Select the answer/s that best describe your skills

Creative thinker

Good initiator and/or leader

Good at keeping organizations or projects running smoothly

Ayurveda Survey Q19. Select the answer/s that best describe your favorite activities

Physical activity

Physical, competitive activity

Leisurely

Ayurveda Survey Q20. Select the answer/s that best describe the effects of exercise

Mental relaxation

Keeps emotions in check

Keeps weight down

Ayurveda Survey Q21. Select the answer/s that best describe how strongly you hold opinions

Change mind easy

Have opinions - like to share them

Change mind slowly

Ayurveda Survey Q22. Select the answer/s that best describe your tendencies

Fear and anxiety

Anger and frustration

Avoid difficult situations

Ayurveda Survey Q23. Select the answer/s that best describe your sleep

Poor and disturbed

Variable

Excessive

Ayurveda Survey Q24. Select the answer/s that best describe your dreams

Often dream, rarely remember

Relatively easy to remember. Dream in color

Generally only remember if esp intense

Ayurveda Survey Q25. Select the answer/s that best describe your demeanor

Changing moods and ideas

Forceful about expressing ideas and feelings

Steady, reliable, slow to change

Ayurveda Survey Q26. Select the answer/s that best describe your eating tendencies

Like to snack and nibble

Like high protein foods like chicken, fish, beans...

Love fatty foods, breads, starch

Ayurveda Survey Q27. Select the answer/s that best describe your illness tendencies

Nervous disorders and/or Pain.

Fevers, rashes, and/or inflammation.

Fluid retention and/or mucous

Ayurveda Survey Q28. Select the answer/s that best describe your sleep

Light

Usually good

Sound, heavy

Ayurveda Survey Q29. Select the answer/s that best describe your attitude toward money

There to be spent

Spend on activities or items that advance you

There to be saved

Ayurveda Survey Q30. Select the answer/s that best describe your nails

Brittle

Flexible

Strong and thick

Ayurveda Survey Q31. Select the answer/s that best describe your circulation

Cold hands and feet

Good circulation, perspire frequently

Moderate sweating

Ayurveda Survey Q32. Select the answer/s that best describe your pulse

Fast, variable pulse, w/cold hands

Strong, full pulse w/warm hands

Steady, slow, rhythmic pulse, cool hands

Ayurveda Survey Q33. Select the answer/s that best describe your thirst

Variable

Usually thirsty

Rarely thirsty

Anything else you want to share?