Please Complete This Questionnaire as Accurate and Honest as Possible, THANK YOU.
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Original Health Questionnaire.
1 - Is it easy for you to get up on a average morning? Do you feel awake and energized?
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???
Yes
No
Sometimes
2 - Do you eat breakfast in the morning? If YES, what does it normally contain?
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3 - Do you usually eat lunch?
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???
Yes
No
Sometimes
4 - If you skip lunch please what is the reason for doing so and if you have lunch what do you routinely eat?
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5 - Do you find yourself snacking all throughout the day in between meals?
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???
Yes
No
Sometimes
6 - If YES what kinda snacks are you habitually eating?
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7 - Do you drink allot of water all throughout the day?
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???
Yes
No
Little
Only when thirsty
8 - Around what time do you normally have dinner?
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???
18.00
18.30
19.00
19.30
20.00
20.30
21.00
Later
9 - What type of meals do you have over dinner time? Please name only the main dishes.
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10 - Do you always finish with a dessert?
*
???
Yes
No
Sometimes
11 - Do you find yourself snacking between dinner and bedtime? If YES on what?
*
12 - Around what time do you find yourself going to bed?
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???
20.00
20.30
21.00
21.30
22.00
22.30
23.00
23.30
Midnight and later
13 - Do you usually have a good 6-8 hours sleep or are you restless at night?
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14 - Do you feel energized on average all through the day?
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???
Yes
No
Sometimes
15 - Do you have any food allergies you know of and have you been tested for them?
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16 - Are you suffering from any ailments at the moment and if so are you under professional care?
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17 - What is your fitness level and how often do you exercise and what type?
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Very good
Good
Could be better
Terrible
Once a week
Twice a week
Three times and more
Weight training
Aerobics
Stretching
18 - Do you take supplements or medications of any kind? If YES what type, how often, and what is it for? (Short summation is sufficient)
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19 - Did you ever diet before? What kinda diets did you try out? Why did they fail? (Short summation is sufficient)
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20 - Did you ever undertake a cleanse or fast, what type, and how long?
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21 - Which practices do you use to prepare your meals?
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Steaming
Cooking
Baking
Frying
Barbeque
Microwaving
22 - Do you drink coffee and/or any other beverages?
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Yes
No
Sometimes
Teas
sodas
'Natural' Juices (store bought)
Juices & smoothies (home made)
Dairy drinks
23 - Do you drink alcohol and what type?
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Yes
No
Sometimes
Beer
wine
Spirits
24 - Do you smoke and/or take recreational drugs?
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Yes
No
Sometimes
Yes to Drugs
No to Drugs
Occasional user
25 - How frequent are your bowel movements, and do you use any laxatives? And are they easy or difficult ?
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Once a day
Twice a day
Several times a day
Infrequent
Every other day
Few times a week
NO laxatives
USE laxatives
Easy
Difficult
26 - Additional comments
27 - Your name
*
28 - E-mail address
*
Phone
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