Pre-Cleanse Survey Confidential InformationName* First Last City and State* Email* Survey QuestionsHow would you rate your weekly stress level?* Easeful, no stress Periodic stress that I recover from easily Stressful and challenging Off the charts Over the last month how would you rate the quality of your sleep?* Very Poor Poor Good Very Good How 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?* 0-1 2-3 4-5 5+ N/A Do 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?CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
