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The remainder of this form is your "Health & Lifestyle Questionnaire." The questions are designed to:

1. Get you thinking about aspects of your health which need to be addressed

2. Aid you in discovering for yourself the obvious benefits and logic of healthy practices

3. Motivate you to come up with some of your own answers

4.Begin structuring your goals

5.Provide better insight into your current condition, health history, values and beliefs for your counselor and coach

Please take your time and provide detailed, thoughtful answers. The more thorough you are, the better equipped CDH will be in helping you learn to heal yourself.

Thank you and good luck. You are on your way to a healthier life.

1. What time do you wake up Mon-Fri?
 3-4am 4-5am 5-6am 7-8am 8-9am 9-10am 10-11am 11-12 12-1pm 1-2pm 2-3pm Later* Explain Below

2. Saturday and Sunday?
 3-4am 4-5am 5-6am 7-8am 8-9am 9-10am 10-11am 11-12 12-1pm 1-2pm 2-3pm Later* Explain Below

3. What time do you go to bed Mon-Fri?
 6-7pm 8-9pm 9-10pm 10-11pm 11-12pm Later* Explain Below

4. What time do you go to bed Sat-Sun?
 6-7pm 8-9pm 9-10pm 10-11pm 11-12pm Later* Explain Below

5. Briefly discuss why you have this schedule of getting up and going to bed. What is your impression of how this schedule impacts your health? Positive/Negative & how?

6.Do you eat breakfast every day?
When are you most likely to skip breakfast?
What are you most likely to eat for breakfast?
Briefly discuss how your breakfast habits affect how you feel?

7. What is your most common lunch?

8. Where do you eat out for lunch most often?

9. How long do you take for lunch?
10-15min15-30min30-45min45-1hr1-1.5hr1.5-2hr2hr+

10. Do you rush?
 Yes No

11. Do you drink ice water or other cold beverages with your lunch?
 Yes No

12. What are your thoughts on introducing cold fluid into your stomach during digestion? Does it improve or impede digestion and why?

13. How important do you think digestion is to optimum health? In what ways does digestion impact our bodies? (physical, emotional, mental)

14. Please describe one way to help ensure optimal digestion.

15. What foods make you feel in balance or in your best shape to face any challenge?

16. Please describe your ideal meal for preparing for a challenging activity (activity may be mental, physical, emotional, etc…) Please note the activity you have in mind.

17. Do you exercise regularly?
 Yes No

18. What exercises do you do?

19. How often?
1x/wk2x/wk 3x/wk4x/wk5x/wk6x/wkDaily

20. How do you feel afterwards?

21. Would you like to do it more? What is stopping you? (Certainly the symptoms you are experience might seem like an obvious answer and 'severe pain' may be the reason, but we want you to answer this very literally. What is really stopping you?)

22. On a scale of 1-100, how responsible do you feel for your health. Including: vitality, joyfulness, sickness and disease?

23. On a scale of 1-100, how much personal effort are you likely to put into your own health and wellbeing?

24. On a scale of 1-100, how motivated are you to proactively continue educating yourself, with or without outside help?

25. Please elaborate on why you answered how you did in questions 22, 23, & 24.

26. What is your overall impression of your answers on this questionnaire? …and in what direction do you feel your current state of health is headed at this moment?

Some thoughts on what we offer:

There are many ways to deal with illness. At Conscious Digestive Health, we believe that the individual’s confidence in the chosen method of healing is crucial.

The purpose of stating this is to clarify that each individual must be perfectly clear about their goal before they begin. Whether that goal is merely being free of pain, or being free of pain, medication, and surgery is irrelevant to success. If an individual has the precise goal of being well through clinical or natural means, or a mix of both, they must carry out their course of action to its fullest extent in order to ensure the fullest extent of its benefits.

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