Diet and Lifestyle
Name
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1. What percent of your diet is organic?
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2. How long have you incorporated organic food in your diet
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3. Frequency of fast food?
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4. Do you allow refined sugar or corn syrup in your food or drink?
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How many days per week are you exposed to refined sugar?
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everyday
most days
once or twice per week
once in a great while
never
5. Do you filter your water or use bottled water?
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If you do filter your water, what type of filtration do you use?
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How long have you had a filter?
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6. How much water do you drink per day?
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7. Do you exercise?
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Type of exercise
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Frequency of exercise
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8. How much sleep do you get per night?
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Do you sometimes wake and find it difficult to go back to sleep?
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9. Please list all supplements and/or herbs that you are taking and their purpose:
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10. My viewpoint on pharmaceuticals can be described as:
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I take them as recommended by my doctor
I am taking meds but would like to get off
I have avoided all daily medications and might use in emergency
I use supplements/herbs only
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