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Appendix A

Comprehensive Yoga Therapy Assessments

Please use these assessments with clients as a means of understanding them deeply. These assessments were designed to expose individual differences and assist you in formulating an individualized, comprehensive lifestyle program for each client.

Most assessments follow the same format. For example, in the Gunas Assessment, the third answer is always representing a sattvic practice or personality, or in the Five Paths Assessment, “Habitually” indicates a strong aptitude for that path.

Some assessments, however, have mixed results. For example, in the Chakras Assessment, “Habitually” will sometimes expose healthy energy flow and other times the same answer with indicate an area of concern.

With each client, read the Assessments thoroughly and consider the “whole person” as you contemplate the results and best course of action. Remember, Assessments are tools to help hone your dialogue with clients and the directions of your sessions, they are not the ultimate in understanding clients or in designing the program that is best. Rather, Assessments open the door for sincere questions and enquiry into each client’s healing path.

| |Restraining Behaviors (Yamas) |Habitually |Often |Occasionally |Rarely |

|Non-harming | | | | | |

| |I act out my anger physically | | | | |

| |I say mean or hurtful things | | | | |

| |I think about hurting others | | | | |

| |I worry I'm not good enough | | | | |

| |I push myself beyond what is healthy | | | | |

| | | | | | |

|Truthfulness |I make up things that didn't happen | | | | |

| |I tell white lies | | | | |

| |I won’t tell someone something that might get me in trouble | | | | |

| |I can’t speak easily about painful or uncomfortable things | | | | |

| |I fantasize about things that haven't happened yet | | | | |

| |I exaggerate | | | | |

| | | | | | |

|Non-stealing |I take things that aren't mine | | | | |

| |I am unsure how to give myself and others space to be as they are | | | | |

| |I don’t think much about the far-reaching implications of my choices | | | | |

| |(political, environmental, etc.) | | | | |

| |I forget what I am grateful for | | | | |

| |I complain | | | | |

| | | | | | |

|Continence |I go to extremes | | | | |

| |I spread myself too thin | | | | |

| |I sleep with people outside of committed relationships | | | | |

| |I overeat | | | | |

| |I lay around a lot | | | | |

| |I over exercise | | | | |

| | | | | | |

|Non-coveting |I long for things I don't have | | | | |

| |I wish things were different | | | | |

| |I'm jealous of others' success or possessions | | | | |

| |I look forward to my life being different/better | | | | |

| |Positive Habits (Niyamas) |Often |Sometimes |Rarely |

|Purity |I practice good personal hygiene | | | |

| |My home is clean | | | |

| |My workspace is neat and organized | | | |

| |I choose virtuous thoughts | | | |

| |I eat whole foods | | | |

| | | | | |

|Contentment |I'm happy with the way my life is | | | |

| |It's okay if things don't work out | | | |

| |I don’t want things I don't yet have | | | |

| |I believe that all is well in my life | | | |

| | | | | |

|Discipline/Austerity |I maintain a daily routine | | | |

| |I perform tasks even when I don't want to | | | |

| |I incorporate spiritual thought into daily acts | | | |

| |I do my best | | | |

| | | | | |

|Self-Study |I read uplifting, personal growth, or spiritual works | | | |

| |I learn about myself in various situations | | | |

| |I seek to see myself clearly | | | |

| |I endeavor towards improving myself | | | |

| | | | | |

|Surrender |There are lessons in all circumstances | | | |

| |I am okay not knowing the ultimate reason(s) things happen | | | |

| |I have strong faith | | | |

| |I trust a higher power/intelligence | | | |

| |I let go of the end results of my efforts | | | |

| |Psychospiritual Body (Chakras) |Habitually |Often |Sometimes |Rarely |

|Energy Anatomy |I sense energy moving within me | | | | |

| |I notice the “feel” of a location | | | | |

| |I am aware of others' energy | | | | |

| |I notice areas in my body that are more energetically sensitive than others | | | | |

| |I have reoccurring aches, pains, or organ/gland troubles | | | | |

| |I often feel low, lethargic, or “blocked” | | | | |

| | | | | | |

|Root |I feel connected to the earth | | | | |

| |I feel safe and grounded | | | | |

| |There are few serious issues with my family of origin | | | | |

| |My finances are sound | | | | |

| |My digestion is sluggish or too quick | | | | |

| |I have problems with leg muscles or lower joints | | | | |

| | | | | | |

|Sacral |I am in touch with physical sensations | | | | |

| |My reproductive organs are healthy | | | | |

| |I am creative | | | | |

| |My urinary organs are healthy | | | | |

| |I am aware of my true emotional feelings | | | | |

| |I enjoy sex | | | | |

| |I have trouble with my reproductive functions | | | | |

| |I have issues with my low back or sacrum | | | | |

| | | | | | |

|Solar Plexus |I have a sense of purpose | | | | |

| |I am confident | | | | |

| |My stomach is healthy | | | | |

| |I have low self-esteem | | | | |

| |I experience stomachaches | | | | |

| |I have acid reflux | | | | |

| |I have problems with my middle back | | | | |

| |I slouch | | | | |

| | | | | | |

|Heart |I experience joy in life | | | | |

| |I freely give | | | | |

| |I easily receive love | | | | |

| |My heart and circulation are healthy | | | | |

| |I have moved through my grief | | | | |

| |I have upper back issues | | | | |

| |I have chest pains | | | | |

| |I have rounded shoulders | | | | |

| | | | | | |

|Throat |I speak the truth | | | | |

| |I express myself kindly | | | | |

| |I am able to listen, even when I don't like what I'm hearing | | | | |

| |My neck and shoulders are relaxed | | | | |

| |I voice my feelings when appropriate | | | | |

| |I talk too much | | | | |

| |I often get sore throats | | | | |

| |I have neck and shoulder tension/pain | | | | |

| | | | | | |

|Third Eye |I see situations clearly | | | | |

| |I follow my intuition | | | | |

| |My mind is clear and calm | | | | |

| |I have strong visual senses | | | | |

| |I get headaches | | | | |

| |I am prone to migraines | | | | |

| | | | | | |

|Crown |I spend time in spiritual company | | | | |

| |My bones are strong | | | | |

| |My skin is clear and healthy | | | | |

| |I am a spiritual person | | | | |

| |I have rigid beliefs | | | | |

| | | | | | |

|Self-Report |Areas I most notice tension/blockages are: |

| | |

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| | |

| |I believe my main chakra/energetic issues are: |

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| | |

| |Life Force Winds (Prana Vayus) |Habitually |Often |Occasionally |Rarely |

|Prana - Heart to Throat:| | | | | |

|Respiration | | | | | |

| |My body feels light and able | | | | |

| |I feel filled with energy | | | | |

| |My heart feels physically/emotionally stable | | | | |

| |My lungs feel strong | | | | |

| |I have a strong inhalation | | | | |

| |I can inhale for a long time | | | | |

| |My senses are clear | | | | |

| | | | | | |

|Apana - Navel to Soles: | | | | | |

|Elimination | | | | | |

| |My body elimination is strong and regular | | | | |

| |I feel fluid sexual energy, physically and mentally | | | | |

| |I have a strong exhalation | | | | |

| |I can exhale for a long time | | | | |

| |I easily let things go | | | | |

| |I feel grounded | | | | |

| |I am confused | | | | |

| |Other people affect my thoughts, feelings, and decisions | | | | |

| |I am lazy | | | | |

| | | | | | |

|Samana - Navel to Heart:| | | | | |

|Discrimination/ | | | | | |

|Assimilation | | | | | |

| |My digestion is balanced and strong (it is easy to eat a variety of | | | | |

| |foods; I don’t experience upset stomach) | | | | |

| |I seek out what is good for me in life | | | | |

| |I feel fire and power in the body | | | | |

| |My emotions sit in the stomach | | | | |

| |My digestion is hot and acidic | | | | |

| |My digestion is weak and cool/gassy | | | | |

| |I experience greed, anger, and/or lust | | | | |

|Udana - Throat to Head: | | | | | |

|Uplifting | | | | | |

| |I have clear speech | | | | |

| |I express words as well as thoughts | | | | |

| |I have a joyful perception of life | | | | |

| |I easily communicate what I’m thinking | | | | |

| |I feel energy in my head when meditating/breathing | | | | |

| |I have respiratory issues | | | | |

| |I experience chronic sore throat | | | | |

| | | | | | |

|Vyana – Pervasive: | | | | | |

|Circulation | | | | | |

| |I am physically strong | | | | |

| |I experience a solid mind-body connection via the nervous system | | | | |

| |I feel united with my authentic self | | | | |

| |I experience a sense of “flow” in life | | | | |

| |I am balanced, physically and mentally | | | | |

| |I quickly adapt to changes in environment | | | | |

| |I have healthy interpersonal boundaries | | | | |

| | | |

|Therapist Observation | | |

| |The strength of inhale: | |

| |The strength of exhale: | |

| |Client’s energy level: | |

| |Ask where energy (fire) is spent: | |

| |Note client’s ability to translate meaning through words: | |

| |Other: | |

| | | |

| | | |

Facets of Reality - GUNAS

Reflecting on your behavior over the last 4 months, please choose which of the following three statements is most accurate for you:

O I don’t go to bed on time and my sleep is disrupted periodically through the night

O Sleep is great and it's a challenge to get up sometimes

O Sleep is a regular part of my routine

O I recharge by resting, reading, watching TV

O I recharge by exercising, socializing, cleaning

O I recharge through meditation, prayer, and spiritual practice

O When stressed, I generally crave chocolate, candy, and chips

O When stressed, I generally crave caffeine, meat, or spicy foods

O When stressed, I generally crave vegetables, grains, and nuts

O My thoughts are slow and my mind tends to feel cloudy

O My thoughts tend to race and my mind often feels full

O My thoughts are changing and my mind watches this

O I have few relationships and am often lonely

O My relationships are full and active

O I have a few, close relationships

O Other people do a better job than I do

O I work hard to make sure things are the way they should be

O I do my best so it doesn't bother me if things don't work out

O When faced with an addictive substance, I avoid it completely so it won't get a hold on me

O When faced with an addictive substance, I consume it and enjoy the effect it has on me

O When faced with an addictive substance, I evaluate whether or not it is the best choice to consume it

O I worry I’m not good enough

O I work hard to prove myself

O I feel worthy

O It’s hard to get going

O I am ambitious

O I work at a measured pace

O I’m lazy

O I’m high energy

O I’m active and restful

|Five Paths of Spiritual Practice |

|Path | |Habitually |Often |Occasionally |Rarely |

|Love |I am a people person | | | | |

|(Bhakti) |I feel spiritually connected when loving and giving | | | | |

| |I feel spiritually inspired in relationships | | | | |

| |I am a religious person | | | | |

| |I am devoted to a Higher Power or spirituality | | | | |

| |I follow my heart not my head | | | | |

| | | | | | |

|Knowledge |I seek to understand spirituality | | | | |

|(Jnana) |I study spiritual works | | | | |

| |I study myself | | | | |

| |I learn about myself in relation to spiritual texts | | | | |

| |I am introspective | | | | |

| |I seek the larger picture | | | | |

| |I surrender my entire ego and act as pure Spirit | | | | |

| | | | | | |

|Psychology |I meditate | | | | |

|(Raja) |I seek inner balance | | | | |

| |I learn about the workings of my ego | | | | |

| |I am interested in the workings of the mind | | | | |

| |I see spirituality in psychology | | | | |

| |I follow the eight-fold path of the Yoga Sutras | | | | |

| | | | | | |

|Work |My efforts serve others and the community at large | | | | |

|(Karma) |I perform to the best of my abilities in all situations | | | | |

| |I see my work as a spiritual opportunity, no matter the job/task | | | | |

| |I am living a purposeful life (I have a personal purpose to my actions) | | | | |

| |I let go of the end results, before, during, and after my work on the task | | | | |

| | | | | | |

|Physical |I learn about and spend time improving my health | | | | |

|(Tantra) |I practice Hatha Yoga (poses, breathing, mind) | | | | |

| |I study the chakras/bioenergy systems of the body | | | | |

| |I enjoy nutritious food and exercise | | | | |

| |Sex is sacred or a form of meditation/spiritual practice | | | | |

| |I balance the energies of the body, nature, and medicine | | | | |

When performing a daily task, such as cooking, I think of [choose one]:

A. Cooking as a practice of love and devotion towards those who will be fed

B. Cooking as a duty; there no attachment to how it turns out or is enjoyed, as long as I did my best

C. The chance to practice body awareness, proper posture and movement, and deep breathing

D. Finding a meditative zone while cooking

E. Seeing the larger picture and organizing an effortless meal

|Bhakti Yoga - Path of Love and Devotion |Habitually |Often |Occasionally |Rarely |

|I love spiritual practice/God | | | | |

|I derive spiritual gratification from my relationships | | | | |

|I ask for feedback in relationships | | | | |

|I reach out to others | | | | |

|My mind is still when I am with others | | | | |

|I accept myself as I am | | | | |

|I accept others as they are | | | | |

|I am open about who I am and rarely “put on a face” | | | | |

|I understand the roots of my emotional needs | | | | |

|I am able to receive what I need emotionally | | | | |

|I seek counseling for my emotional issues | | | | |

|I am not defensive when others ask me to change a behavior | | | | |

|I compromise easily | | | | |

|I consider others’ ideas and listen to their concerns | | | | |

|I listen to others and try to understand where they are coming from | | | | |

|I learn as much as I can about those I love | | | | |

|When I have an aversion to a task or new idea, I consider the reason of its | | | | |

|greater good | | | | |

|I look for the soul or authentic self in everyone | | | | |

|I follow through on what I say I will do for others | | | | |

|I am bright and enthusiastic at work | | | | |

|I am loving and devoted towards those I care about | | | | |

|I help people who are helping others | | | | |

|I support those who are sad or ill | | | | |

|I let go of unsupportive friendships | | | | |

|I don’t pay attention to negative or harming people | | | | |

|I try to make others happy | | | | |

|My romantic partnership is stressful (if applicable) | | | | |

|I think of my own needs in relationships before others’ | | | | |

|I feel inadequate in relationships | | | | |

|I am afraid of abandonment or people being mad at me | | | | |

|I have unresolved issues with my family of origin | | | | |

|I want things from those around me | | | | |

|I focus on what others should change | | | | |

|I feel frustrated when loved ones don’t agree with me | | | | |

|When others speak, I think of what I’m going to say next, or how to respond | | | | |

|I offer advice | | | | |

|I have a lot to say | | | | |

|I complain to others | | | | |

|Karma Yoga - Path of Work and Action |Habitually |Often |Occasionally |Rarely |

|I enjoy my job | | | | |

|My mind is calm at work | | | | |

|I am bright and enthusiastic at work | | | | |

|I am willing to take risks at work | | | | |

|I am willing to perform all of my work tasks | | | | |

|I focus on the task at hand | | | | |

|I focus on solutions | | | | |

|I focus on obstacles and challenges | | | | |

|I break tasks down into smaller, more manageable tasks | | | | |

|I set clear and measurable daily and weekly goals | | | | |

|I do my best in all areas of work | | | | |

|I meet my deadlines | | | | |

|Excellence is important to me, no matter how small the job | | | | |

|I do not worry about the results of my hard work | | | | |

|I am not defensive when receiving constructive feedback | | | | |

|I ask for feedback about my performance | | | | |

|Others would say I have an excellent attitude about work | | | | |

|I compromise with my coworkers | | | | |

|I consider others’ ideas and listen to coworkers’ concerns | | | | |

|I learn as much as I can about the company I work for, including others’ roles in | | | | |

|the whole | | | | |

|I care about the company I work for | | | | |

|I feel my pay is on par with the work I perform | | | | |

|My job gives me a sense of purpose | | | | |

|When I have an aversion to a task or new idea, I consider the reason of its | | | | |

|greater good | | | | |

|I inspire coworkers | | | | |

|I support others’ work | | | | |

|I am generous with my time, skills, and possessions | | | | |

|I am punctual | | | | |

|I rarely call in sick | | | | |

|My workspace is clean and organized | | | | |

|I help customers, clients, and coworkers to the best of my abilities when they are| | | | |

|rude or aggressive | | | | |

|I am inspired by life | | | | |

|I prioritize my personal/spiritual growth above all else | | | | |

|I put family or work above my personal growth needs | | | | |

|I work more than 40 hours per week | | | | |

|I bring work home with me, either physically or mentally | | | | |

|My job is stressful | | | | |

|I feel inadequate at work | | | | |

|I am afraid of failure | | | | |

|When others have less work to do, I expect them to help me with my work | | | | |

|I have troubled relationships with coworkers or supervisors | | | | |

| |Layers of Human Existence - Koshas |Habitually |Often |Occasionally |Rarely |

|Body | | | | | |

| |I exercise regularly | | | | |

| |I follow a healthy nutritional plan | | | | |

| |I get 6-9 hours of sleep per night | | | | |

| |I connect to the purpose of eating | | | | |

| |I eat when I’m hungry | | | | |

| |My doctor supports and advocates for holistic wellness | | | | |

| |I frequently contract colds or feel under the weather | | | | |

| | | | | | |

|Breath/ Energy | | | | | |

| |I regularly practice slowing and deepening my breath | | | | |

| |I am aware of the subtleties of my experiences | | | | |

| |I am aware of the energy in food | | | | |

| |My daily routine supports stress-free living | | | | |

| |My energy levels are steady and regular | | | | |

| |I hold or shorten my breath without noticing | | | | |

| | | | | | |

|Mind |I am kind to myself | | | | |

| |I spend time in nature | | | | |

| |I am strongly affected by sensory stimuli | | | | |

| |I live in a busy area | | | | |

| |I am driven by my emotions | | | | |

| |I experience eyestrain, ringing in ears, or other sensory afflictions | | | | |

| |I have to see it to believe it | | | | |

| |I keep music or the television on most of the time | | | | |

| |I am easily distracted | | | | |

| |My emotions guide my choices | | | | |

| |Past experiences effect my current emotions | | | | |

| | | | | | |

|Intellect | | | | | |

| |I read spiritual resources | | | | |

| |I witness my feelings and experiences | | | | |

| |I observe my inner environment impassively | | | | |

| |I am logical | | | | |

| |I am aware of the effect of nutrition, exercise, breathing, spirituality, and| | | | |

| |creativity on my well-being | | | | |

| |I use thoughts to calm my emotions | | | | |

| |I am often accused of “not getting it” | | | | |

| |Past experiences effect my thoughts and perceptions | | | | |

|Spirit | | | | | |

| |I make time for spiritual reflection | | | | |

| |I am aware of spiritual context or beauty in everyday situations | | | | |

| |I am comforted by a connection to "something more" | | | | |

| |My daily actions lead to spiritual fulfillment | | | | |

| |I meditate or have spiritual practice at the same time each day | | | | |

| |I feel fulfilled | | | | |

| |I am a member of a spiritual or artistic community | | | | |

| |I have spiritual mentors and teachers | | | | |

| |I have had “peak experiences” or moments of profound personal meaning in life| | | | |

| |My community supports holistic living | | | | |

| |I have strong, unwavering beliefs | | | | |

Koshas Self-Assessment Diary: Nutrition for the Whole Person

Instructions: Throughout the day, (every time you change activities; every hour; at significant times) log what you are “feeding” yourself on each level of being. Follow this format/make copies and stick to the process for at least one week.

|Time |Activity |Body |Breath |Mind |Intellect |Spirit |

|8am |Prepare for work |Omelet, juice, tea |Rapid, shallow |Fearful, stressed |Making lists, |Largely ignored; |

| | | | |Surrounded by noise |planning day |noticed birds in tree |

| | | | |(TV, radio) | | |

|10am |Morning Break |Did yoga poses |Deep during poses |Found quiet place |Slowed down |Grateful for time for |

| | | | |Relaxation happened | |myself and effects of |

| | | | | | |poses |

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Koshas Inspiration Chart

Instructions: Now that you have completed the Self-Assessment Diary for a consistent period of time, you are more aware of your habits and “nutrition” for all levels of your being. For the next week (at least) follow the same format, this time adding suggestions about how you may offer your entire self a more nourishing life.

|Time |Activity |Body |Breath |Mind |Intellect |Spirit |

|8am |Prepare for work |Omelet, juice, tea|Rapid, shallow |Fearful, stressed |Making lists, |Largely ignored; |

| | | | |Surrounded by noise |planning day |noticed birds in tree |

| | | | |(TV, radio) | | |

|Modify |Be mindful |Say grace; taste |Deepen breath |Enjoy music from one |Mindfulness |Appreciate and be |

| | |food | |source, or silence |Be present rather |grateful for morning |

| | | | | |than project future |experiences |

|Modify | | | | | |Allow effects of |

| | | | | | |practice to remain |

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| | | | | | |activities |

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|I eat whole foods | | | | |

|I eat 4 servings of vegetables per day | | | | |

|I eat 2 servings of whole fruit per day | | | | |

|My heart palpitates if meals are missed or delayed | | | | |

|Most of my protein comes from plant sources | | | | |

|I eat 2 to 3 servings (the size of my fist) of protein per day | | | | |

|I drink at least 1 liter of water per day | | | | |

|I move my bowels at least once per day | | | | |

|I limit prescription medications | | | | |

|I limit recreational drugs | | | | |

|I limit alcohol | | | | |

|I do not eat dessert | | | | |

|I limit even hidden sugars in foods | | | | |

|I drink coffee | | | | |

|I drink 2 glasses of fruit juice per day | | | | |

|I limit convenience foods | | | | |

|I limit white flour and refined foods | | | | |

|I limit caffeine | | | | |

|I limit fast foods | | | | |

|I don’t use artificial sweeteners | | | | |

|I drink one or more soft drinks per day | | | | |

|I have an excessive appetite | | | | |

|I have a low appetite | | | | |

|I eat when I’m nervous | | | | |

|I get lightheaded if meals are delayed | | | | |

|If I am feeling fatigued, eating relieves it | | | | |

List any drug, supplement or food allergies: _________________________________________________

Please list all current medications and supplements: _________________________________________

Are you or have you ever been on any special diets? If yes, please list: ___________________________

Food Self-Assessment Diary: Food Relationships

Instructions: You may use this form as a template, make copies of it, or find your own way to discover similar things. Notice your physical and emotional state, your breath and thoughts, before and during each meal. If you don’t notice anything (you might not at first) just say “fine”. Stick to the process for at least one week. Do not judge yourself or feel guilty, just notice and be honest. This process will help you understand yourself and make healthy, long term changes in food as well as physical and emotional well-being. If you miss recording a meal, do your best to remember or just skip it and record the next one.

|Time |Food (preparation, amount) |Hunger (0-5) |Physical |Mind/Mood |Situation |

|7am |Whole wheat toast w coconut butter, 2-egg omelet|4 |Deep breathing |Hurried; |Preparing for work |

| |with broccoli, peppers, avocado, 1/2c. juice | |Neck ache |Happy to eat |Planning day |

| |with protein powder | | | | |

|10am |Carrots and hummus |2 |Rapid breath |Work stress |Ate at desk; Others nearby|

| |Craved chocolate bar; didn’t buy one | |Neck and headache |Hard to focus on food |talking about major work |

| | | | | |project |

|12pm |¼ pound hamburger, 2 handfuls of French fries, |3 |Sad, Rapid/ Shallow |Worried Depressed |Trying to take a break |

| |12 oz. soft drink | |breath, low energy | |from stressful day |

|3pm |Chocolate bar |1 |Low energy, shallow |Stressed, hard to |Wanted to sleep; thought |

| | | |breath, fatigued |concentrate |sugar would wake me up |

|6pm |Steamed Fish and Veggies |4 |Before Eating achy, |Clear/At peace Happy |Optimistic; made healthy |

| | | |tired After Eating | |dinner choice and felt |

| | | |breathing calm/deep | |better |

|10pm |Herbal tea |2 |Deep breathing, |Content, calming down |Bedtime |

| | | |tired |for sleep | |

|7am |Granola and organic yoghurt, green juice |5 |Hard to wake up, |Spent time deep |Optimistic; plan to have a|

| |(celery, kale, ginger, apple), 1 hardboiled egg | |body tired after |breathing while packing|better day |

| | | |restless night |nutritious lunch; | |

| | | | |content | |

|10am |Leafy greens, goat cheese, walnuts, almonds, |3 |Relaxed, consciously|Choosing thoughts to |Work stress continues; not|

| |figs, prunes salad | |taking deep breaths;|keep stress away – |worrying just working |

| | | |chewed slowly |affirmations and mantra| |

|12pm |Avocado, Swiss chard, beet, tomato, soy cheese |3 |Body tight, breath |Used lunchtime to |Choosing thoughts; eating |

| |wrap with cashew gravy. Protein shake | |shallow |relax, deepen breath |in park across from office|

|3pm |Carrot sticks; almonds, Finish protein shake; |2 |Eyes hurt, neck ache|Run down |angry with boss |

| |Craved chocolate bar; didn’t buy one | | | | |

|6pm |Bean chili, brown rice, plain yoghurt, green |3 |Fatigued, more |Frustrated from work |Glad to be home; going |

| |onions | |relaxed |week; trying to calm |out to movie with friend |

| | | | |self | |

|11pm |Herbal tea |1 |Sleepy; ache gone, |Feel restored and happy|Glad it’s Friday – no work|

| | | |breath deep |from friend |tomorrow |

Food Self-Assessment Diary: Food Relationships

Instructions: You may use this form as a template, make copies of it, or find your own way to discover similar things. Notice your physical and emotional state, your breath and thoughts, before and during each meal. If you don’t notice anything (you might not at first) just say “fine”. Stick to the process for at least one week. Do not judge yourself or feel guilty, just notice and be honest. This process will help you understand yourself and make healthy, long term changes in food as well as physical and emotional well-being. If you miss recording a meal, do your best to remember or just skip it and record the next one.

|Time |Food (preparation, amount) |Hunger (0-5) |Physical |Mind/Mood |Situation |

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PHYSICAL QUESTIONAIRRE

MOVEMENT

What are the physical/movement requirements of your job? ___________________________________

What sports and activities do you participate in? _____________________________________________

SKELETAL

Are you concerned about your bone density? ________________________________________________

Have you had a bone density test and if so, what were the results? ______________________________

Do you experience joint pain? ____________________________________________________________

Repetitive clicks/cracks: _________________________________________________________________

SPINE

Do you have back problems? _____________________________________________________________

_____________________________________________________________________________________

Have you ever been diagnosed with a spinal condition? ________________________________________

*Note articulation of spine through 4 directions: _____________________________________________

*Posture standing and seated: ____________________________________________________________

NERVES

How easy is it for you to relax? ___________________________________________________________

Are you easily stressed? _________________________________________________________________

*Affective presentation: _________________________________________________________________

MUSCLES

How flexible are you? ___________________________________________________________________

If not flexible, did you lose flexibility over time or have you never been flexible? ____________________

Considering your size, how strong are you? _________________________________________________

Range of motion: ______________________________________________________________________

*Timed resistance (plank): _______________________________________________________________

ORGAN FUNCTION

Are you concerned about the health of any systems in your body? (heart, lungs, digestive, etc) ________

If so, why? ____________________________________________________________________________

Have you ever been diagnosed with a condition in any organ or any other chronic condition (describe)?

Do you experience irregular or rapid heartbeat? _____________________________________________

Do you have regular bowel movements? ____________________________________________________

GLANDS

Have you ever been told by a health professional you have abnormal hormone levels? ______________

Do you experience night sweats or hot flashes? ______________________________________________

Are you very sensitive to ambient temperature? _____________________________________________

Are you over or underweight, independent of your diet and exercise? ____________________________

BREATHING

Count the number of seconds of the average breath:

Average inhale _____ seconds

Average pause after inhale _____ seconds

Average exhale _____ seconds

Average pause after exhale _____ seconds

Notice your breath through the course of the day:

My breath is shortest/more rapid/erratic at _________________ time of day

My breath is longest/steadiest/deepest at _________________ time of day

Other observations: _________________________________________________________________

Notice your breath in various postures, such as in bed, on the couch, at the computer, driving, exercising, standing in line, etc.:

Side of my body I tend to constrict: _______________________________________________________

Breathing dominance through either nostril or mouth: ________________________________________

Areas of my lungs I tend to constrict (diaphragm, intercostals, chest): ____________________________

Phase of breath I tend to limit (inhale, exhale, pause after either): _______________________________

Symptoms of erratic breathing (stutters, phases, shakiness, etc): ________________________________

Relate any of these observations to emotional state or thought patterns: _________________________

Other observations: ____________________________________________________________________

LIFESTYLE

What medications are you on? ___________________________________________________________

What are the side effects of these medications? ______________________________________________

Do these side effects impact your concentration? ____________________________________________

What supplements do you take? __________________________________________________________

Do you eat 5 servings of vegetables per day, where at least one is a leafy green? ___________________

What are you ready to work on? __________________________________________________________

What will you not change? _______________________________________________________________

Who else is on your personal health care team and what role do they play? _______________________

On one page, list all the activities you do each week and the times. Include your work schedule, meal times and general type of food, television time, spiritual practice, social life, exercise, etc. Also include on the list any dreams and future plans.

On a second page, place "balanced health" with a circle around it in the center of the page. Draw another circle that divides the remaining space in half. Inside of this second circle draw a few arrows toward the center, and outside the circle draw a few arrows pointing away from the center. Place the activities that keep you in balanced health in the first circle (practice Yoga, visit parents, exercise, etc.) and the activities that take you away from health (drinking alcohol, over-working, etc.) in the outside circle. We will attempt to work on shifting all activities to the circle leading to balanced health or limiting the activity if it cannot be changed.

Psychological Blocks - KLESAS

|Ignorance (Avidya) |Habitually |Often |Occasionally |Rarely |

|I believe in "something more" | | | | |

|I regularly connect to my spirit or a sense of peace | | | | |

|I get over hurts and tragedies quickly | | | | |

|I am aware of the spiritual in everyday moments | | | | |

|My regular activities offer spiritual benefits | | | | |

|When painful circumstances arise, I suffer | | | | |

|I become very sad, angry, or negative when my body is injured or in pain | | | | |

|I am my body | | | | |

|I am very sad when happy occasions end | | | | |

|I need something to look forward to | | | | |

|I get lost in stressors and worries | | | | |

Describe a time when you felt a "peak experience", such as something breathtaking, unexplainable, touching, or profound. __________________________________________________________________

List the activities you perform regularly to connect to your spirit or a Higher Power? _______________

|Ego (Asmita) |Habitually |Often |Occasionally |Rarely |

|I see myself without the bias of others’ expectations | | | | |

|I work for the welfare of myself and others | | | | |

|I easily see others’ points of view | | | | |

|I accept others’ quirks and shortcomings | | | | |

|I accept my quirks and shortcomings | | | | |

|I feel “less than” others or experience low self-esteem | | | | |

|I think, therefore I am | | | | |

|I take things personally | | | | |

|I have a busy mind | | | | |

|I talk a lot | | | | |

Who are you? _________________________________________________________________________

|Attachment (Dvesha) |Habitually |Often |Occasionally |Rarely |

|I have a list of "wants" | | | | |

|I know what I like | | | | |

|I seek pleasure | | | | |

|I indulge in junk foods, alcohol, drugs, television, Internet usage, pornography, | | | | |

|or other sensual pleasures | | | | |

|I tend to seek happiness outside of myself | | | | |

|I am jealous, clingy, or possessive | | | | |

|Once I find a yoga center, church, or other community, I stick with it exclusively| | | | |

|Right is right and wrong is wrong | | | | |

|When I am not around what makes me happy, I am no longer happy | | | | |

|When I like something, I want more of it | | | | |

|When I lose something I love, I feel like a part of myself is gone | | | | |

List your likes: _________________________________________________________________________

|Aversion (Raga) |Habitually |Often |Occasionally |Rarely |

|I am compassionate to my own emotions | | | | |

|I stay away from things I don’t like | | | | |

|I avoid things and people I don’t like | | | | |

|I wish my body or personality were different | | | | |

|I wish my life were different | | | | |

|I have a hard time thinking about/focusing on things or situations I don’t like | | | | |

|I feel sick when I think about/am around things/people/situations I don’t like | | | | |

|I pray to avoid painful or “bad” situations | | | | |

|I need something to look forward to | | | | |

List your dislikes: _______________________________________________________________________

|Fear (Abinivesha) |Habitually |Often |Occasionally |Rarely |

|I cope well with change | | | | |

|If I died tomorrow, I would be satisfied with my legacy OR reflect upon my life | | | | |

|without regrets | | | | |

|I don’t like change | | | | |

|I am frightened about my mortality | | | | |

|I am concerned about the future | | | | |

|I have many worries | | | | |

|I am fearful | | | | |

|I lack strong faith | | | | |

|I make sure my life is carefully planned | | | | |

What do you think happens when we die? __________________________________________________

Other comments about your fears: ________________________________________________________

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