Pre-Cleanse Survey Confidential InformationName* First Last City and State*Email* Survey QuestionsHow would you rate your weekly stress level?*Easeful, no stressPeriodic stress that I recover from easilyStressful and challengingOff the chartsOver the last month how would you rate the quality of your sleep?*Very PoorPoorGoodVery GoodHow many hours a night on average do you sleep?*What is your main health concern?*What do you hope to gain through this cleanse?*Headache*NeverOnceOftenBloating*NeverOnceOftenGas*NeverOnceOftenConstipation*NeverOnceOftenDiarrhea*NeverOnceOftenFatigue*NeverOnceOftenExhaustion*NeverOnceOftenJoint Aches*NeverOnceOftenPain*NeverOnceOftenSkin Rash*NeverOnceOftenIn a typical day, how many cups of coffee or other caffeinated beverages (i.e., soda, black tea etc.) do you drink?*0-12-34-55+N/ADo you have any dietary restrictions?*What percentage of your food is home cooked?*0-25%25-50%50-75%75-100%Is there any thing else you would like to share?