Healthy Home Questionnaire
This is not intended to shame but to analyze your home & families current healthy living status. We can only get where we want to go by first knowing where we are at.
Name
First Name
Last Name
Email
example@example.com
IG Handle
Do you regularly: (Check those that apply to you)
Exercise
Meditate
Journal
Ground
If you exercise, please indicate which type of exercise you engage in.
Walking
Strength Training
Cardio/Running
Yoga/Pilates
What is your source of drinking & cooking water?
Tap Water
Well Water
Filtered Water
Bottled Water
If purchasing bottled water, how much do you spend a month?
If Water is filtered, please indicate which type of filter.
Brita Pitcher
Reverse Osmosis
Above counter filter
Whole House Filter
Other
What type of cookware do you use to cook your food?
Ceramic
Cast Iron
Aluminum
Stainless Steel
Coated Finish
Does anyone in your home suffer from any of the following:
Asthma/ Emphysema
Allergies
Eczema or Psoriasis
Sleep Disorders
Do you own any pets?
Yes
No
Do you own air purifiers?
Yes
No
Are you buying organic ingredients?
Yes
No
Sometimes
Are you Familiar with the Dirty Dozen?
Yes
No
How much do you eat out?
3-5 x per week
1-2 x per week
Barely Ever
Do you limit the use of harsh chemicals?
Yes
No
Sometimes
Are there any concerns of toxicity in your home?
What health aspects would you like to improve on in your home & family?
Should be Empty: