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Sama Ayurveda

samabeauty@gmail.com

805-570-2692

Form Section 1

Health & Wellness Assessment

Full Name
Full Address
Marital Status
Form Section 2
Form Section 3
Form Section 4
Work Satisfaction
Family Life
Social Life
Form Section 5
How would you describe your digestion?
Do you eat your meals at the same time each day? Give or take 30min.
Which is your larger meal of the day?
How much water do you drink a day?
What's your eating habit like?
Describe your diet.
How would you describe your bowel movements.
Bowel nature
Form Section 6
How is your energy throughout the day?
Form Section 7
Do you experience any of the following? Choose any that apply.
How purposeful does your life feel?