Date
First Name
Last Name
Race / Heritage
Gender
Please select
Male
Female
Birth Date
Age
Height
Please select
Please select
inches
centimeters
Body Weight
Please select
Birth Place
Current Living Place
From Year
To Year
Parents
Please select
Birth Parents
Adoptive Parents
Foster Parents
No. of Brothers
Please select
None
1
2
3
4
5
more
No. of Sisters
Please select
None
1
2
3
4
5
more
Are you the eldest, youngest, etc?
Please select
Eldest
Youngest
In Between
Only Child
Marital Status
Please select
Single
Married
Divorced
Widowed
For how long?
No. of Children
Please select
None
1
2
3
4
5
more
Ages
Education
Work (describe) + (hours per day) ?
Leisure (describe) + (hours per day) ?
Exercise (describe) + (hours per day) ?
Hobbies
Yoga personal practice:
Yoga (self) - no. of years have you been practicing ?
Yoga (self) - no. of times you practice per week ?
Yoga Style / Description
Yoga Teaching:
Yoga (work) - no. of years have you been teaching ?
Yoga (work) - no. of times you teach per week ?
Ayurveda personal practice:
Ayurveda (self) - no. of years have you been practicing ?
Ayurveda (self) - no. of times you practice per week ?
Ayurveda professional:
Ayurveda (work) - no. of years working in professional care ?
Ayurveda (work) - no. of times you work per week ?
Personal Medical Information:
What is your current Health condition ?
Are you receiving any Healing Treatments ?
Are you taking any Supplements or Medication ?
Do you have any previous Medical History ?
Color Photo - Head View (jpg)
Color Photo - Full Body View (jpg)
When you submit this Self History Profile information it is confidential and sent only to Tedd Surman, Yoga Awareness.
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