Basics

01 / 10

How old are you?

Height and Weight BMI Calculator

pounds
inches

Diet

02 / 10

How many servings of vegetables do you have a day?

Are you a vegetarian or vegan?

Are you a strict carnivore?

How many alcoholic drinks do you have a week?

How many times a week do you eat fast food or processed food from a box or bag?

How many times a week do you eat at a sit down restaurant?

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Sleep

03 / 10

How many hours of sleep do you get a night?

How many times do you wake up a night on an average WEEKLY BASIS?

Do you snore?

Do you sleep and wake up at consistent times each day?

Do you avoid blue light 2 hours before bedtime?

Do take any sleep medications?

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Body

04 / 10

How many times a week do you exercise?

What do you do for exercise?

Are you in pain?

Do you stretch?

Do you have a self care and healing routine like cold plunge, use of saunas, etc.

About how many steps do you get in a day

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Mindset

05 / 10

How would you quantify your level of stress. (0 = none, 10 = extremely high)

How would you rate your spirituality?

How do you describe your general mood? (0 = "Positive, hopeful, energetic, passionate", 5 = "Meh", 10 = "Depressed, apathetic, anxious, obsessive, stressed")

How would your describe your life satisfaction? (0 = High, 10 = Low)

How worried are you about your health? (0 = No, 10 = Extremely)

How motivated are you to prevent disease and enjoy vital health? (0 = Extremely, 5 = Somewhat, 10 = Not motivated at all)

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Medical

06 / 10

Have you been diagnosed with any of the following?

Are you taking any medications currently?

What would you like to improve?

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GUT

07 / 10

Has your poop been consistent. (0 = "Solid and at the same time of day daily", 5 = "Sometimes runny and some times solid", 10 = "I have stomach issues")

Have you taken antibiotics or NSAIDs. (0 = "None in the last year", 5 = "Some in the last year", 10 = "Frequently in the last year")

Have you experienced blood in your stool or unexplained consistent pain in your stomach? (0 = "No", 5 = "Sometimes", 10 = "Frequently")

Have you experienced unintentional weight changes? (0 = "No", 5 = "Sometimes", 10 = "Yes,Frequently")

Do you have any symptoms of skin irritations like redness or patches of itchy skin? (0 = "No", 5 = "Sometimes", 10 = "Yes")

Does your stomach hurt or get upset after a meal? (0 = "Never", 5 = "Sometimes", 10 = "Frequently")

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TOXINS

08 / 10

How mindful are you about your personal care products. (0 = "I use databases to shop for my non-toxic products", 5 = "I buy some less toxic products", 10 = "I used the major brands and have never thought about thte toxicity")

Do you eat organic foods. (0 = "All the time", 5 = "Occasionally", 10 = "Rarely")

Do you use a water filter. (0 = "I have a central line filter", 5 = "I filter my drinking water", 10 = "No I drink bottled water")

Do you use an air filter. (0 = "Yes. I filter my home and work area", 5 = "I have a filter at either home or office", 10 = "No")

Do you own any non-stick cookware? (0 = "None at all", 5 = "I have a few", 10 = "They are all non-stick")

Have you done any detox programs in the last year? (0 = "I've done a few", 5 = "Once", 10 = "None at all")

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Customer Information

09 / 10
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