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Pre-Detox Health Questionnaire
Email
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?
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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)
10
9
8
7
6
5
4
3
2
1
Are you able to commit to showing up live for our weekly coaching call (or watch the replay within 24 hours)?
Yes
No
Submit
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