Pre-Detox Health Questionnaire

First name

Last name

Please tell me what is bothering you. If this involves a specific health condition or illness, please tell me about it in as much detail as possible. Describe carefully any factors that you think may have played a role in its onset and progression.*

Is your health currently getting worse, better, or staying the same? How do you know?*

What have you tried to do to improve your state of health (i.e. other doctors, treatments, etc.)?*

Do you think the pain and/or symptoms that you are experiencing could be purposeful? That is, could they be your body’s wisdom saying, “I need some help...let’s change some things here!” Please explain:*

Do you feel your pain and/or illness is a reflection of short-term superficial circumstances or longer-term potentially deeper-seated challenges?*

Two months from now, what would make you feel like this detox was a success for you? *

How did you hear about the Transformational Detox? *

Please list any self-destructive lifestyle habits (i.e. smoking, lack of exercise, addictions, etc.)*

Are you currently taking antibiotics or any prescription medications? If so, which ones?*

Are you currently taking any supplements? If so, which ones?*

What makes you happy?*

On a scale of 1-10, how willing are you to put aside what you already know and believe about health, to learn something new? (10 being very willing, 1 being not willing at all)

Are you able to commit to showing up live for our weekly coaching call (or watch the replay within 24 hours)?

Yes

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The information published on this site is not intended to diagnose, treat, cure, or prevent any disease.

The information provided by this website and/or this company is not a substitute for a face-to-face consultation with your physician, and should not be construed as individual medical advice.

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