What body weight category are you? Lean Average Overweight Obese
Have you found it difficult to lose weight no matter what you try? Yes No Doesn’t apply
You feel tired: Only when it's bedtime In the late afternoon Around noon All the time
How often do you move your bowels? Once a day Twice a day Once every other day A few times a week
How many processed foods do you eat a day (anything from a box or package)? 1 or less 2-4 servings 5-9 servings 10 or more servings
What is the frequency of your alcohol intake? Never 1-3 days a week 4-5 days a week Everyday
How often do you consume artificial sweeteners including Splenda®, Sweet 'N Low®, and/or Equal® found in diet beverages and food items? 1 to 2 times a week 3 to 6 times a week Every day Never
Check the box next to each condition that you experience on a regular basis Constipation, gas, bloating, Acid reflux or indigestion Skin problems (Eczema or acne) Overall sickness Bad breath Urinary tract infections Sugar cravings Celiac disease, leaky gut, or irritable bowel syndrome Depression, anxiety, mood disorders Insulin resistance or diabetes
How often do you use laxatives or antacids? Never 1-3 days a week 4-5 days a week Everyday
How often do you chew sugarless gum or use mouthwash? Never 1-3 days a week 4-5 days a week Everyday
How many times have you taken antibiotics during your lifetime? Never 1-3 times 4-5 times More than 5 times
How often do you eat foods with high amounts of sugar including soft drinks and desserts? Never 1-3 days a week 4-5 days a week Everyday
How often do you drink chlorinated (tap) water including unfiltered ice cubes? Never 1-3 days a week 4-5 days a week Everyday
Do you eat organic fruit, vegetables, meats and dairy products or regular store bought varieties? Organic Regular
How often do you eat foods like unpasteurized raw yogurt (this does not include regular yogurt sold in most grocery stores), sauerkraut, kimchi, fermented vegetables, fermented raw milk (kefir), and tempeh? Never 1-3 days a week 4-5 days a week Everyday
