Questionnaire

In order to make changes in how you look and feel, it will be helpful to evaluate your present health practices and level of awareness. This questionnaire will help you to identify areas you may want to work on either during the 21-Day Program offered in my books or with me personally through my clinical services, coaching practice or a personal retreat.

Instructions: For each question, answer Y for yes or often, S for sometimes or somewhat, and N for no or rarely. After you have completed the questionnaire, you will have a feeling for the areas which need more attention and conscious support. I have complete scoring instructions in both of my books.


	1. Diet
a.	Do you make a point of eating natural, whole foods?	Y	S	N
b.	Do you eat animal protein more than once a day?	Y	S	N
c.	Do you eat packaged or processed foods?	Y	S	N
d.	Do you make an effort to avoid insecticides and other chemicals in foods?	Y	S	N
e.	Do you ever notice any physical or mental symptoms (e.g., headache, stomach pain, rash, drowsiness, irritability) after eating a certain food?	Y	S	N
f.	Do you eat fresh fruits or vegetables every day?	Y	S	N
g.	Do you drink six to eight glasses of water every day?	Y	S	N
h.	Do you drink tap water?	Y	S	N

	2. Eating Habits
a.	Do you eat in a calm, relaxed setting, without distractions?	Y	S	N
b.	If you are angry or upset, do you try to calm down before eating?	Y	S	N
c.	Do you chew your food well?	Y	S	N
d.	Do you tend to overeat?	Y	S	N
e.	Do you eat when you are not hungry?	Y	S	N
f.	Do you regularly eat out in restaurants?	Y	S	N

	3. Weight Control
a.	Are you comfortable with your present weight?	Y	S	N
b.	Are you overweight?	Y	S	N
c.	Are you underweight?	Y	S	N
d.	Do you have a history of crash dieting?	Y	S	N
e.	Do you tend to eat compulsively to avoid dealing with emotional issues?	Y	S	N

	4. Digestion
a.	Do you often feel bloated and full after eating?	Y	S	N
b.	Do you notice after eating particular foods that you tend to be bloated or uncomfortable?	Y	S	N
c.	Do you experience heartburn or gas pains after eating?	Y	S	N

	5. Elimination
a.	Do you move your bowels every day?	Y	S	N
b.	Do you move your bowels in direct proportion to what you eat (i.e., two meals a day equals two bowel movements)?	Y	S	N
c.	Are your stools hard?	Y	S	N
d.	Are you generally constipated?	Y	S	N
e.	Do you get constipated before your menstrual period?	Y	S	N

	6. Energy Level
a.	Would you describe your energy level as generally low?	Y	S	N
b.	Are you aware of the fluctuations in your energy level during the day?	Y	S	N
c.	Are these changes in energy level so dramatic that they keep you from doing things you would like to do?	Y	S	N
d.	Does your energy level seem to increase or decrease in relation to meals?	Y	S	N
e.	As you grow older, do you notice your energy level decreasing?	Y	S	N

	7. Exercise
a.	Would you describe yourself as physically fit?	Y	S	N
b.	Do you do some form of aerobic activity, such as brisk walking, for one-half hour at least three times a week?	Y	S	N
c.	Do you do yoga or other stretching exercises?	Y	S	N
d.	Do you walk or ride a bicycle regularly, rather than taking a bus or car?	Y	S	N

	8. Breathing
a.	Do you have frequent respiratory infections or bronchitis?	Y	S	N
b.	Does your abdomen expand when you breathe?	Y	S	N
c.	Do you tend to breathe through your mouth?	Y	S	N
d.	Do you do any regular breathing exercises?	Y	S	N
e.	Do you notice that you hold your breath or hyperventilate when you are nervous or angry?	Y	S	N

	9. Rest and Sleep
a.	Do you sleep six to eight hours a night?	Y	S	N
b.	Do you sleep more than nine hours at night?	Y	S	N
c.	Do you have trouble falling asleep?	Y	S	N
d.	Do you have trouble getting up in the morning?	Y	S	N
e.	Do you wake up during the night?	Y	S	N

	10. Stress Level
a.	Would you rate the general stress level in your life as high?	Y	S	N
b.	Do you hold a lot of stress in your body?	Y	S	N
c.	Do you know which parts of your body tend to become tense or painful when you are under stress?	Y	S	N
d.	Does your job produce stress for you?	Y	S	N
e.	Do your family or your personal relationships produce stress for you?	Y	S	N
f.	Are you able to express your anger?	Y	S	N

	11. General Appearance and Personal Hygiene
a.	Do you feel that you are too rapidly showing signs of aging?	Y	S	N
b.	Do you floss your teeth every day?	Y	S	N
c.	Are your teeth in need of repair?	Y	S	N
d.	Do you have bad breath?	Y	S	N
e.	Do you have an unpleasant body odor?	Y	S	N
f.	Do you look bloated or puffy?	Y	S	N
g.	Do you have a protruding tummy, in spite of all your efforts at diet and exercise?	Y	S	N

	12. Skin, Hair, and Nails
a.	Is your skin either extremely dry or very oily?	Y	S	N
b.	Do you often have blemishes on your face, back, or other parts of the body?	Y	S	N
c.	Is your hair dry and dull?	Y	S	N
d.	Are your nails weak, ridged, or bitten?	Y	S	N
e.	Do you have cellulite?	Y	S	N
f.	Do you use antiperspirants or deodorants containing aluminum or other chemical compounds?	Y	S	N

	13. Menstrual Cycle
a.	Does your menstrual period occur in a regular cycle?	Y	S	N
b.	Is the flow about the same every cycle?	Y	S	N
c.	Do you have severe menstrual cramps?	Y	S	N
d.	Do you have a lot of bloating before your period?	Y	S	N
e.	Do you have an increased tendency to get angry, anxious, or depressed just before your period?	Y	S	N
f.	Are you having any uncomfortable symptoms as a result of nearing or undergoing menopause?	Y	S	N

	14. Sexuality
a.	Are you satisfied with your sexual drive?	Y	S	N
b.	Does decreased or excessive libido cause problems in your relationship?	Y	S	N
c.	Do you crave more touch or nurturing than you are presently receiving?	Y	S	N
d.	Do you practice “safe sex”?	Y	S	N

	15. Emotional and Mental Health
a.	Do you notice mood swings throughout the day, the week, or the month?	Y	S	N
b.	Do you get angry easily?	Y	S	N
c.	Do you cry easily?	Y	S	N
d.	Do you laugh a lot?	Y	S	N
e.	Do you use any stimulants, depressants, or other drugs (legal or illegal) to affect your mood or alertness?	Y	S	N

	16. Substance Use
a.	Do you drink more than one caffeine beverage each day?	Y	S	N
b.	Are you concerned about your tobacco use?	Y	S	N
c.	Do you drink alcohol more than you think you should?	Y	S	N
d.	Do you need support in dealing with your use of any of these substances?	Y	S	N

	17. Environment
a.	Are you pleased with the overall appearance and atmosphere of your home environment?	Y	S	N
b.	Do you have natural light, fresh air, and green plants or access to nature in your living space?	Y	S	N
c.	Is there a quiet place in your home where you can have complete privacy for an hour or more?	Y	S	N