Questionnaire

Name

City, State, Country

Phone Number

Email address

Birthday

How many meals do you eat per day?

How much time do you spend on each meal?

What times of the day do you eat?

How would you describe the way you eat?

Are you a vegetarian or vegan? If so, How long?

Do you eat or drink on a regular basis...

Meat

Dairy (milk, eggs, cheese)

Vegetables

Fruits

Sweets (chocolate, candy, desserts, etc)

Fried foods

Raw foods

Soft drinks (soda, canned/bottled juices, etc)

Caffenated drinks

Coffee

Alcohol

Filtered/purified water

What do you eat/drink most often?

What foods do you crave?

How do you choose your food (taste, health, calories, carbs, convenience, etc)?

Do you cook your own foods? How often?

Do you own a juicer? How often do you use it?

Do you exercise? What type and how often?

Describe how you you sleep?

Do you take any supplements? If so, what?

Do you take any medications? If so, for what?

Have you ever done a fast/cleanse? What type/how long?

If yes, what was your reason for doing it?

What was your experience like?

Do you currently do any spiritual/contemplative practices (yoga, meditation, tai chi, etc) Please describe.

Do you believe in a Higher Power?

If so, can you describe your spiritual beliefs (religion, etc)?

My health is... (good, bad, declining, important, etc)