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Please select your gender.

What is your age range?

 18-30

 30-40

 40-50

 50+

What body weight category are you?

 Lean

 Average

 Overweight

 Obese

I feel my mental clarity is:

 Crystal clear, crisp, sharp

 Mostly clear with very occasional moments of fuzzy brain

 Moments of clarity mixed with fuzziness, like 50%/50%

 My brain feels cloudy and fuzzy 90% of the time

My stress levels on any given day is:

 Low

 Moderate

 High

My exercise habits are:

 Everyday

 3-5 days a week

 1-3 days a week

 Never

Are you or were you a smoker, or do you live with one?

 No

 I live with a smoker

 I used to but quit

 I am a smoker

What is the frequency of your alcohol intake?

 Never

 1-3 days a week

 3-5 days a week

 Everyday

How many fresh fruits & veggies do you eat everyday?

 9 or more servings

 5-9 servings

 2-4 servings

 1 or less

How many processed foods do you eat a day (anything from a box or package)?

 1 or less

 2-4 servings

 5-9 servings

 9 or more servings

Do you order take out or dine out 4 or more times per week?

 Never

 Sometimes

 Every Week

How often do you move your bowels?

 Once a day

 Twice a day

 Once every other day

 A few times a week

How much water do you drink per day?

 At least 8 glasses

 5-7 glasses

 2-4 glasses

 1 or less

Does Your Belly:

 Lay firmly above your pants

 Rest a little bit over your belt

 Overlaps your waist line

Do you live in the:

 Country

 Suburbs

 City

How many massages do you get in 1 year?

 More than 6 times

 3-6 times a year

 1-2 times a year

 Never

Do you use standard household cleaners?

 Use organic & chemical free

 Use a mix of chemical free and conventional cleaners

 Use conventional cleaners

Have you ever detoxed or cleansed your body?

 I detox regularly 4-6 times a year

 It's been over a year since my least detox or cleanse

 I've tried a cleanse once before

 Never

I feel tired:

 only when it's bedtime

 In the late afternoon

 Around noon

 All the time

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