Lifestyle Questionnaire





    Typical Day











    Please Rate the Following

    How do you sleep?
    1 - Poor2345678910 - Perfect

    How is your digestion?
    1 - Poor2345678910 - Perfect

    How is your elimination?
    1 - Poor2345678910 - Perfect

    Rate your stress level
    1 - Poor2345678910 - Perfect (no stress)

    Rate your happiness level
    1 - Poor2345678910 - Perfect

    Rate your health level
    1 - Poor2345678910 - Perfect



    Satisfaction






    Final Questions

    Do you meditate?




    Do you have a yoga practice?




    Do you exercise?




    Do you drink caffeine ?




    Do you use tobacco?









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