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How many bottles of water do you drink daily?
Your answer
Do you drink alcohol?
Yes
No
Clear selection
Do you currently smoke?
Yes
No
Clear selection
Do you typically have breakfast?
Yes
No
Clear selection
What do you typical have for breakfast?
Your answer
What time do you typically have breakfast?
Your answer
What time do you typically have dinner?
Your answer
How many times daily do you have raw vegetables?
Your answer
Do you drink water first in the morning?
Yes
No
Clear selection
Do you experience any of the following?
Constipation
Bloating
Pile
Diarrhea
Ulcer
Reflux
Gas
How many times do you have bowel movement in a day?
Your answer
What time do you go to bed? -How many hours do you sleep per night?
Your answer
What time do you wake up?-How many times do you wake up during the night?
Your answer
Rate your stress level on scale1-10 (1=Low,10=high)
1
2
3
4
5
6
7
8
9
10
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Rate your energy level on scale 1-10 (1=Low,10=high)
1
2
3
4
5
6
7
8
9
10
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Do you currently exercise?
Yes
No
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Do you have any health challenge? Please list
Your answer
Would you like us to contact you with your wellness score? Kindly fill out the following:
Your answer
Name:
Your answer
Age:
Your answer
Phone:
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Email:
Your answer
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