Holistic living workshop

Workshop Mode Online Offline
Venue: From: To:
Time: To: No of Days:

Name:    Age: yrs
Gender: Options Male Female Occupation: Options Student Service H-Wife Research Scholar

Mob No::    Email Id::    Willing to join google group: YES NO

Purpose of practicing holisticyog (Holistic Health Information).

Physical:
Weight control fitness digestion disorder respiratory trouble joint pain back pain Thyroid B.P sugar tired feeling allergies   other if any:

Psychological/Emotional:
Insomnia Mood Swing Lacking Motivation Respiratory trouble Poor Concentration Fear Anger Anxiety Restlessness Stress Loneliness Boredom Depression Low Self Esteem   
other :

Spiritual:
Want of inner peace Unable to enjoy life and work Difficult relationship Failed affairs    Any other specific issues and concerns:

Doctor's diagnosis for chronic disease (if any):

Any recent surgery (if any):

Are you currently any type of medication?:

I declare that, all relevant information given by me on this form is correct to my belief and take the responsibility for myself in attending holistic-yog workshop and any consequences thereof.

date:
Signature of Participant:

Note: If one has any doubt whether 'holisticyog' can be practiced with a particular health conditions, consult beforehand and inform any ill feeling to the instructor during practice.

Registration: Rs  Remuneration: Rs 

+For On Line Payment - Acct. No: 10224422221 Name Tapas Kumar Maili IFSC-SBIN0000202