100 Days of Detox and Wellness

Take the quiz to see which detox is best for you. If we find something potentially alarming on your quiz we’ll direct you to book a free call to go over our findings and discuss your recommended next steps.Green de Vine

Email* This field is required.Please enter the email address where you would like to receive the detox information.

example@example.com

Phone NumberPlease enter your phone number. All responses are confidential.

Please enter a valid phone number.

Herpesvirus Diagnosis* This field is required.Have you ever been diagnosis or told by a doctor that you have a herpes virus such as: HSV 1 or 2, cold sores, shingles, mono, Epstein Barr, or Cytomegalovirus?

YESNO

Medical Conditions* This field is required.Please select all of the following conditions that apply to you:

HSV 1 or 2

HPV (human papiloma virus)

Shingles

Espstein Barr

Cytomegalovirus

Diabetes

Overweight

High Blood Pressure

Metabolic Disorder

Hormonal imbalance Like Fibroids, Cysts, Endometriosis, PCOS, Thyroid Disease etc.

Something Else

Other

Please ExplainYou selected that you have a medical condition that's not on the list. Please explain below.

Dietary Intake* This field is required.Do you eat at least 2-3+ large meals per day?

YESNO

Food Intake: Be truthful with your answers.Do you eat any of the following foods more than twice a month? If you do not eat these foods often or on the regular, you should select NO. * Broccoli * Berries (strawberries, black berries, blue berries, etc) * Okra * nuts and seeds (peanuts, peanut butter, pistachios, almonds, pumpkin seeds, sunflower seeds, walnuts, black walnut, pecans, flax seeds, chia seeds) * mushroom coffee * oat milk, almond milk, or cashew products * raisins or grapes * collard greens or mustard greens or cabbage * raw spinach and raw kale in smoothies or salads.

YESNO

Food Intake: Be truthful with your answers.Which of the following foods do you eat?

Broccoli

Berries (strawberries, black berries, blue berries, etc)

okra

nuts and seeds (peanuts, peanut butter, pistachios, almonds, pumpkin seeds, sunflower seeds, walnuts, black walnut, pecans, flax seeds, chia seeds)

mushroom coffee

oat milk, almond milk, or cashew products

raisins or grapes

collard greens or mustard greens or cabbage

raw spinach and raw kale in smoothies or salads.

More DetailsHow often do you eat the foods you selected from the list?

Dietary* This field is required.What is your current diet?

Currently Detoxing or Fasting

Standard American

Plant Based (Vegetarian or Vegan)

Pescartarian

Carnivore (meat only, no veggies, no fruit)

Recent Detoxes* This field is required.Have you done a detox or cleanse in the last 3 months?

Fruit only or (80/20 fruits and vegetables)

Raw fruit and vegetable

Cooked fruit and vegetables

Fasting (intermittent fasting or no food)

Recent DetoxesHow long were you on this detox?

Physical Activity* This field is required.Do you workout regularly, run, or play sports at least once a week?

Light workouts

Strenuous workouts

Physical Activity* This field is required.Do you have a physically demanding job? (Heavy lifting or often feel sore from work)

YESNO

Physical ActivityPlease explain the type of work you do.

Stress Assessment* This field is required.How would you rate your current stress levels?

Quality of Sleep* This field is required.How many hours of sleep do you get daily?

2-4 hours

5-6 hours

7-9 hours

10+ hours

Habits* This field is required.Are you addicted to cigarettes, marijuana, or another type of drug that you would not be able to quit for the detox?

YESNO

Prescription Medications* This field is required.Are you on prescribed medication?

Yes, Psych Meds

Yes, High Blood Pressure, Thyroid, or Diabetes Meds

Yes, Birth Control

Yes, some other Medication

More DetailsYou selected that you take a medication that is not on the list. What prescription meds do you take?

Over the Counter Medications* This field is required.Are you taking over the counter medications regularly that you cannot stop without your doctor's recommendation?

YESNO

More DetailsPlease list the over the counter medications that you take.

Supplements & Herbs* This field is required.Have you taken any herbs or herbal supplements within the last 60 days?

YESNO

More DetailsPlease list the over the Supplements and Herbs that you take or took within the last 60 days.

You Completed the Quiz* This field is required.Are you ready to detox?

YESNO

Admin Tag: Passed Or Failed

Passed

Failed

Was Supposed To Pass

100 Days of Detox and Wellness