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Detoxification Program - Health Questionnaire

12/16/2015

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Please click below to complete our intensive health questionnaire. This survey will take you approximately 20-30 minutes to complete, and must be completed in its entirety to submit. Please start completing the form at a time when you can calmly devote the time and energy to completing it without distractions.

The purpose of filling out this questionnaire is to give detailed information to individualize an herbal regimen to accompany a detoxification program. While fasting and cleansing can be done simply through juicing or eating only raw vegan, or fruitarian; the addition of herbs can assist the body in alkalizing, moving lymph, eliminating toxins through the kidneys, liver, and intestines, as well as ridding the body of parasites. 
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To begin filling out the survey, click the " Read More" button below.

    Personal Information

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    Thyroid Questions


    Parathyroid Questions

    Pancreas Questions

    Adrenal Gland Questions


    For Women 


    For Men


    Gastro-Intestinal Questions


    Liver / Gall Bladder / Blood


    Heart and Circulation Questions


    Skin Questions


    Lymphatic System Questions


    Kidneys and Urinary Bladder Questions


    Lung Questions


    Environmental and Toxic Exposure Questions


    Other Pertinent Information

    Please be honest and share a typical day of what you ingest for meals, snacks, and beverages. No judgment!
    How many bowel movements do you have per day and per week?
    Please list all current medications and their purpose.
    Congratulations! You have completed the survey! Click submit to send the info to Ronit.
Submit
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