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LIFESTYLE EVALUATION QUESTIONNAIRE
QuanticAdmin
2020-05-27T20:25:52+00:00
Lifestyle Evaluation Questionnaire
Name
How many organs removed? (Please specify which ones below and age) - don't forget adenoids, tonsils, appendix, gall bladder, uterus or ovaries.
How many synthetic drugs are you taking? (Please list name, dosage and what they are for)
What over the counter vitamins are you currently taking?
Amount of times you smoke per day? (Use daily average over last 2 months)
Number of steroid type drugs used in the last year e.g Cortisone? (Please specify below)
Number of metal amalgam fillings (any metal fillings in teeth)
Number of street drugs used in the last month? (Total number of different types used - specify)
Have you ever used street drugs? Yes / No? If yes, please specify below
Number of known allergies confirmed by a doctor?
I am responsible for my body? (0-10) 0 = not at all responsible; 10 = completely responsible
0
1
2
3
4
5
6
7
8
9
10
Amount of fat in diet as a percentage out of 100%? (Most diets are over 40% fat, 20% is ideal)
Number of unresolved mental factors? Eg: Anger / greed / desire / sadness / fear / childhood trauma / abandonment / abuse / death of a loved one if you are comfortable to, please list briefly:
Number of sugar type products per day? (Any use of white processed sugar or wheat on average per day, incl sweets, biscuits, soft drinks, sugar in tea or coffee)
Number of exercise sessions per week of 20 min or more not including work? (Count only official workouts that end in sweat)
Number of alcoholic drinks per day / month?
Number of cups of coffee / tea per day (caffeine is in chocolate, cola and other foods too)
Number of extreme toxic exposures in the last year? (Insecticides, radiation, chemicals, include each chemotherapy and radiation treatment as well as accidental exposures)
Number of major injuries in past? (Count all emotional, physical or other traumas) - Please specify below:
Number of major infections past and present? (Count all major health threatening infections) - Please specify below:
Number of glasses of water per day?
How many kilograms if you perceive yourself to be overweight?
Personal Stress? 0 = not at all stressed; 10 = completely stressed
0
1
2
3
4
5
6
7
8
9
10
Interpersonal Stress
0
1
2
3
4
5
6
7
8
9
10
Work / School Stress
0
1
2
3
4
5
6
7
8
9
10
Struggle with Self
0
1
2
3
4
5
6
7
8
9
10
Struggle with Money
0
1
2
3
4
5
6
7
8
9
10
Stress from Sickness
0
1
2
3
4
5
6
7
8
9
10
Family Stress
0
1
2
3
4
5
6
7
8
9
10
Stress from desire for things to be different
0
1
2
3
4
5
6
7
8
9
10
Problem with bowels
0
1
2
3
4
5
6
7
8
9
10
Problem with sweat
0
1
2
3
4
5
6
7
8
9
10
Problem with urine
0
1
2
3
4
5
6
7
8
9
10
Problem with mucous
0
1
2
3
4
5
6
7
8
9
10
Problem with nausea
0
1
2
3
4
5
6
7
8
9
10
Problem with menses
0
1
2
3
4
5
6
7
8
9
10
Problem with breath
0
1
2
3
4
5
6
7
8
9
10
Problem with skin
0
1
2
3
4
5
6
7
8
9
10
Problem with sleep
0
1
2
3
4
5
6
7
8
9
10
How many times a day do you meditate or use stress reduction techniques?
Number of Root Canal Treatments?
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