New SMART – Commonsense Health

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Personal Information & Preferences

All information obtained in this questionnaire will be held confidential and will only be used to construct the most viable protocol for you.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (Optional)//

Email *

May we send you reminders and suggestions via Whatsapp? *

Yes, but only one a day
Yes, but no more than 3 per day
Yes
No

Phone *

Please enter your country code before you enter your phone number?

Preferred Scale *

Imperial
Metric

Medical Related

These questions are designed to establish an overall view of your health issues. It also gives you a baseline to compare your progress to.

Is it your GOAL and wishes to become disease free? *

This seems like a stupid question when you get to it, but you need to make a conscious decision to what you want.

What "disease" are you suffering from? *

Aids
Allergies
Arthritis
Autoimmune Diseases
Cancer
Diabetes
Eczema
Heart Condition
Hypertension
Lyme disease
Osteoporosis
Overweight
Raspatory Problems
STD
Stomach Ulcers
Tuberculosis
Other

Multiple options are possible.

What other diseases do you suffer from? *

Then please tell us why you want to take part in this Questionnaire? *

Weight (lb) *

Weight (kg) *

Height (inch) *

Height (cm) *

Body Mass Index (BMI) *

To calculate your BMI go to https://www.calculator.net/bmi-calculator.html

Blood Pressure

Example: 125/65 If you do not know your blood pressure, leave this blank and go to the next question.

Blood Cholesterol

If you do not know your blood cholesterol level, leave this blank and go to the next question.

Blood Sugar

If you do not know your blood sugar level, leave this blank and go to the next question.

Indicate any plant-based allergies *

Gluten
Peanuts
Tree Nuts
Sesame Seed
Soy
Honey
Other
None

Multiple options are possible.

Please describe any other plant-based allergies *

Where are you *

In a hospital
At Home
In a care center

Are you dependent on anybody for basic needs? *

For going to the bathroom, do grocery shopping and especially cooking?

Who is your biggest support (the person you can count on) *

Docter
Nurse
Care taker
Family member
Friend
None

How many hours can your support person attend to your wellbeing per day *

0 -1 hrs
1 - 2 hrs
2 - 4 hrs
4 + hrs

Can you prepare your own meals? *

Yes, but with lots of effort
Yes
No

Who prepare your meals? *

My support person prepare my meals
The hospital/care center prepare my meals

Would your support person be able to help with preparing some meals? *

You are not alone. We are here for you. We are so sorry that you don't have anybody close to support you! You will always have our support from this site. The best advice that we can give you at this stage is to follow our Fools Protocol until you are well enough to continue with the SMART pH Protocol. *

Exit

Life Style

What is your current week like? *

	Mostly resting in Bed	Mostly at Home	Mostly at Leisure	Work up to 4 Hours	Work up to 8 Hours	Work up to 12 Hours
Monday	Monday Mostly resting in Bed	Monday Mostly at Home	Monday Mostly at Leisure	Monday Work up to 4 Hours	Monday Work up to 8 Hours	Monday Work up to 12 Hours
Tuesday	Tuesday Mostly resting in Bed	Tuesday Mostly at Home	Tuesday Mostly at Leisure	Tuesday Work up to 4 Hours	Tuesday Work up to 8 Hours	Tuesday Work up to 12 Hours
Wednesday	Wednesday Mostly resting in Bed	Wednesday Mostly at Home	Wednesday Mostly at Leisure	Wednesday Work up to 4 Hours	Wednesday Work up to 8 Hours	Wednesday Work up to 12 Hours
Thursday	Thursday Mostly resting in Bed	Thursday Mostly at Home	Thursday Mostly at Leisure	Thursday Work up to 4 Hours	Thursday Work up to 8 Hours	Thursday Work up to 12 Hours
Friday	Friday Mostly resting in Bed	Friday Mostly at Home	Friday Mostly at Leisure	Friday Work up to 4 Hours	Friday Work up to 8 Hours	Friday Work up to 12 Hours
Saturday	Saturday Mostly resting in Bed	Saturday Mostly at Home	Saturday Mostly at Leisure	Saturday Work up to 4 Hours	Saturday Work up to 8 Hours	Saturday Work up to 12 Hours
Sunday	Sunday Mostly resting in Bed	Sunday Mostly at Home	Sunday Mostly at Leisure	Sunday Work up to 4 Hours	Sunday Work up to 8 Hours	Sunday Work up to 12 Hours

What do you do for a living? *

For example - pilot, mechanic, shopkeeper, banker, student, lawyer, stay at home parent, retired, etc.

Do you or have you ever live in, work in or regularly pass a hazardous area containing *

Mold
Asbestos
Radiation
Poisonous Chemicals
Heavy Industry
Industrial Farming
I am not sue

Multiple options are possible.

Describe your mobility *

I am bound to a wheelchair
I can walk with assistance
I can walk slowly
I can walk fast
I can jog
I can run

Religious beliefs *

I am a dedicated Christian (Roman Catholics)
I am a dedicated Christian (Protestant)
I am a dedicated Christian (Jew)
I am a dedicated Christian (Other)
I believe in most Christian teachings
I am dedicated to the Islamic religion
I believe in most Islamic teachings
I am a dedicated Hindu
I believe in Spirituality
I am a Naturalist
I believe in God
I am an Atheist

How often do you have bowel movement? *

30 - 60 minutes after a meal
1 - 3 hours after a meal
3 - 8 hours after a meal
More than 8 hours after a meal

How much do you sleep? *

Less than 5 hours
5 - 6 hours
6 - 8 hours
More than 8 hours

How good is your hearing? *

I am deaf
I can hear with my hearing aid
I can hear clearly

How good is your eye sight? *

I am blind, but have supporting person that can read for me
I can only see when I have my glasses on
I cannot read without my glasses
I can read without my glasses
I have 20/20 vision

How many people do you take care off? *

Only for Myself
Myself and 1 sibling
Myself and 2 siblings
Myself and 3-4 siblings
Myself and 5+ siblings

People that you have to cook for on a daily basis. Siblings include partners and elderly people for which you are responsible for.

Which days and times are you free to do whatever you want? *

	None	Morning	Afternoon	Evening
Monday	Monday None	Monday Morning	Monday Afternoon	Monday Evening
Tuesday	Tuesday None	Tuesday Morning	Tuesday Afternoon	Tuesday Evening
Wednesday	Wednesday None	Wednesday Morning	Wednesday Afternoon	Wednesday Evening
Thursday	Thursday None	Thursday Morning	Thursday Afternoon	Thursday Evening
Friday	Friday None	Friday Morning	Friday Afternoon	Friday Evening
Saturday	Saturday None	Saturday Morning	Saturday Afternoon	Saturday Evening
Sunday	Sunday None	Sunday Morning	Sunday Afternoon	Sunday Evening

This will be the time that you will be able to do grocery shopping, marathon cooking (preparing meals for the week), attend church and/or sporting events and to visit friends or family. You can choose more than one time period per day. If you choose None and another time period, then we will accept that you accidentally entered another time period and will do the protocol schedule with None free time for that day.

How much fluid do you drink each day? *

	0 Cups	1 - 2 Cups	3 - 4 Cups	5 - 6 Cups	6+ Cups
Coffee	Coffee 0 Cups	Coffee 1 - 2 Cups	Coffee 3 - 4 Cups	Coffee 5 - 6 Cups	Coffee 6+ Cups
Tea	Tea 0 Cups	Tea 1 - 2 Cups	Tea 3 - 4 Cups	Tea 5 - 6 Cups	Tea 6+ Cups
Green Tea	Green Tea 0 Cups	Green Tea 1 - 2 Cups	Green Tea 3 - 4 Cups	Green Tea 5 - 6 Cups	Green Tea 6+ Cups
Energy Drinks	Energy Drinks 0 Cups	Energy Drinks 1 - 2 Cups	Energy Drinks 3 - 4 Cups	Energy Drinks 5 - 6 Cups	Energy Drinks 6+ Cups
Soda	Soda 0 Cups	Soda 1 - 2 Cups	Soda 3 - 4 Cups	Soda 5 - 6 Cups	Soda 6+ Cups
Commercial Juice	Commercial Juice 0 Cups	Commercial Juice 1 - 2 Cups	Commercial Juice 3 - 4 Cups	Commercial Juice 5 - 6 Cups	Commercial Juice 6+ Cups
Fresh Juice	Fresh Juice 0 Cups	Fresh Juice 1 - 2 Cups	Fresh Juice 3 - 4 Cups	Fresh Juice 5 - 6 Cups	Fresh Juice 6+ Cups
Green Juice	Green Juice 0 Cups	Green Juice 1 - 2 Cups	Green Juice 3 - 4 Cups	Green Juice 5 - 6 Cups	Green Juice 6+ Cups
Fresh Smoothies	Fresh Smoothies 0 Cups	Fresh Smoothies 1 - 2 Cups	Fresh Smoothies 3 - 4 Cups	Fresh Smoothies 5 - 6 Cups	Fresh Smoothies 6+ Cups
Still Water	Still Water 0 Cups	Still Water 1 - 2 Cups	Still Water 3 - 4 Cups	Still Water 5 - 6 Cups	Still Water 6+ Cups
Sparkling Water	Sparkling Water 0 Cups	Sparkling Water 1 - 2 Cups	Sparkling Water 3 - 4 Cups	Sparkling Water 5 - 6 Cups	Sparkling Water 6+ Cups
Filtered Water	Filtered Water 0 Cups	Filtered Water 1 - 2 Cups	Filtered Water 3 - 4 Cups	Filtered Water 5 - 6 Cups	Filtered Water 6+ Cups
Mineral Water	Mineral Water 0 Cups	Mineral Water 1 - 2 Cups	Mineral Water 3 - 4 Cups	Mineral Water 5 - 6 Cups	Mineral Water 6+ Cups
Ionized Alkaline Water	Ionized Alkaline Water 0 Cups	Ionized Alkaline Water 1 - 2 Cups	Ionized Alkaline Water 3 - 4 Cups	Ionized Alkaline Water 5 - 6 Cups	Ionized Alkaline Water 6+ Cups

1 Cup = 250ml

If you checked them, please describe the "Fresh Juice", "Green Juice", "Fresh Smoothies" and "Ionized Alkaline Water" that you consume?

Fresh Juice = bought at shop, home made, ingredients - Green Juice = bought at shop, home made, ingredients - Fresh Smoothies = bought at shop, home made, ingredients - Ionized Alkaline Water = Supplier

How many times do you consume animal products per week? *

	0	1-2 /week	3-4 /week	5-6 /week	6+ /week
Beef	Beef 0	Beef 1-2 /week	Beef 3-4 /week	Beef 5-6 /week	Beef 6+ /week
Chicken	Chicken 0	Chicken 1-2 /week	Chicken 3-4 /week	Chicken 5-6 /week	Chicken 6+ /week
Turkey	Turkey 0	Turkey 1-2 /week	Turkey 3-4 /week	Turkey 5-6 /week	Turkey 6+ /week
Pork	Pork 0	Pork 1-2 /week	Pork 3-4 /week	Pork 5-6 /week	Pork 6+ /week
Venison	Venison 0	Venison 1-2 /week	Venison 3-4 /week	Venison 5-6 /week	Venison 6+ /week
Processed Meats	Processed Meats 0	Processed Meats 1-2 /week	Processed Meats 3-4 /week	Processed Meats 5-6 /week	Processed Meats 6+ /week
Seafood	Seafood 0	Seafood 1-2 /week	Seafood 3-4 /week	Seafood 5-6 /week	Seafood 6+ /week
Eggs	Eggs 0	Eggs 1-2 /week	Eggs 3-4 /week	Eggs 5-6 /week	Eggs 6+ /week
Milk	Milk 0	Milk 1-2 /week	Milk 3-4 /week	Milk 5-6 /week	Milk 6+ /week
Cheese	Cheese 0	Cheese 1-2 /week	Cheese 3-4 /week	Cheese 5-6 /week	Cheese 6+ /week
Yogurt	Yogurt 0	Yogurt 1-2 /week	Yogurt 3-4 /week	Yogurt 5-6 /week	Yogurt 6+ /week
Other	Other 0	Other 1-2 /week	Other 3-4 /week	Other 5-6 /week	Other 6+ /week

Please describe the "Other" animal products that you consume?

How many times do you consume these products per week? *

	0	1-2 /week	3-4 /week	5-6 /week	6+ /week
Deep fried foods	Deep fried foods 0	Deep fried foods 1-2 /week	Deep fried foods 3-4 /week	Deep fried foods 5-6 /week	Deep fried foods 6+ /week
Sunflower / Canola Oil for frying	Sunflower / Canola Oil for frying 0	Sunflower / Canola Oil for frying 1-2 /week	Sunflower / Canola Oil for frying 3-4 /week	Sunflower / Canola Oil for frying 5-6 /week	Sunflower / Canola Oil for frying 6+ /week
Olive / Coconut oil Cold pressed	Olive / Coconut oil Cold pressed 0	Olive / Coconut oil Cold pressed 1-2 /week	Olive / Coconut oil Cold pressed 3-4 /week	Olive / Coconut oil Cold pressed 5-6 /week	Olive / Coconut oil Cold pressed 6+ /week
Butter	Butter 0	Butter 1-2 /week	Butter 3-4 /week	Butter 5-6 /week	Butter 6+ /week
Margarine	Margarine 0	Margarine 1-2 /week	Margarine 3-4 /week	Margarine 5-6 /week	Margarine 6+ /week
White bread	White bread 0	White bread 1-2 /week	White bread 3-4 /week	White bread 5-6 /week	White bread 6+ /week
White flour	White flour 0	White flour 1-2 /week	White flour 3-4 /week	White flour 5-6 /week	White flour 6+ /week
Maize meal	Maize meal 0	Maize meal 1-2 /week	Maize meal 3-4 /week	Maize meal 5-6 /week	Maize meal 6+ /week
Flaxseed	Flaxseed 0	Flaxseed 1-2 /week	Flaxseed 3-4 /week	Flaxseed 5-6 /week	Flaxseed 6+ /week
White Sugar	White Sugar 0	White Sugar 1-2 /week	White Sugar 3-4 /week	White Sugar 5-6 /week	White Sugar 6+ /week
Table salt	Table salt 0	Table salt 1-2 /week	Table salt 3-4 /week	Table salt 5-6 /week	Table salt 6+ /week
Sea salt or Himalayan salt	Sea salt or Himalayan salt 0	Sea salt or Himalayan salt 1-2 /week	Sea salt or Himalayan salt 3-4 /week	Sea salt or Himalayan salt 5-6 /week	Sea salt or Himalayan salt 6+ /week
Other	Other 0	Other 1-2 /week	Other 3-4 /week	Other 5-6 /week	Other 6+ /week

Please describe the "Other" products that you consume?

Describe your AM Schedule? *

	N/A	5-6am	6-7am	7-8am	8-9am	9-10am	10-11am	11-12pm	12-1pm	1-2pm
Wake Up	Wake Up N/A	Wake Up 5-6am	Wake Up 6-7am	Wake Up 7-8am	Wake Up 8-9am	Wake Up 9-10am	Wake Up 10-11am	Wake Up 11-12pm	Wake Up 12-1pm	Wake Up 1-2pm
Breakfast	Breakfast N/A	Breakfast 5-6am	Breakfast 6-7am	Breakfast 7-8am	Breakfast 8-9am	Breakfast 9-10am	Breakfast 10-11am	Breakfast 11-12pm	Breakfast 12-1pm	Breakfast 1-2pm
Go to Work	Go to Work N/A	Go to Work 5-6am	Go to Work 6-7am	Go to Work 7-8am	Go to Work 8-9am	Go to Work 9-10am	Go to Work 10-11am	Go to Work 11-12pm	Go to Work 12-1pm	Go to Work 1-2pm
Go for Treatments	Go for Treatments N/A	Go for Treatments 5-6am	Go for Treatments 6-7am	Go for Treatments 7-8am	Go for Treatments 8-9am	Go for Treatments 9-10am	Go for Treatments 10-11am	Go for Treatments 11-12pm	Go for Treatments 12-1pm	Go for Treatments 1-2pm
Morning Tea Break	Morning Tea Break N/A	Morning Tea Break 5-6am	Morning Tea Break 6-7am	Morning Tea Break 7-8am	Morning Tea Break 8-9am	Morning Tea Break 9-10am	Morning Tea Break 10-11am	Morning Tea Break 11-12pm	Morning Tea Break 12-1pm	Morning Tea Break 1-2pm
Lunch	Lunch N/A	Lunch 5-6am	Lunch 6-7am	Lunch 7-8am	Lunch 8-9am	Lunch 9-10am	Lunch 10-11am	Lunch 11-12pm	Lunch 12-1pm	Lunch 1-2pm
Finish Working	Finish Working N/A	Finish Working 5-6am	Finish Working 6-7am	Finish Working 7-8am	Finish Working 8-9am	Finish Working 9-10am	Finish Working 10-11am	Finish Working 11-12pm	Finish Working 12-1pm	Finish Working 1-2pm
Exercise	Exercise N/A	Exercise 5-6am	Exercise 6-7am	Exercise 7-8am	Exercise 8-9am	Exercise 9-10am	Exercise 10-11am	Exercise 11-12pm	Exercise 12-1pm	Exercise 1-2pm
Relaxing	Relaxing N/A	Relaxing 5-6am	Relaxing 6-7am	Relaxing 7-8am	Relaxing 8-9am	Relaxing 9-10am	Relaxing 10-11am	Relaxing 11-12pm	Relaxing 12-1pm	Relaxing 1-2pm

Should some of these activities take place in the afternoon, just mark them as N/A. Multiple times can be chosen for each activity.

Describe your PM Schedule? *

	N/A	2-3pm	3-4pm	4-5pm	5-6pm	6-7pm	7-8pm	8-9pm	9-10pm	10-11pm
Lunch	Lunch N/A	Lunch 2-3pm	Lunch 3-4pm	Lunch 4-5pm	Lunch 5-6pm	Lunch 6-7pm	Lunch 7-8pm	Lunch 8-9pm	Lunch 9-10pm	Lunch 10-11pm
Go to Work	Go to Work N/A	Go to Work 2-3pm	Go to Work 3-4pm	Go to Work 4-5pm	Go to Work 5-6pm	Go to Work 6-7pm	Go to Work 7-8pm	Go to Work 8-9pm	Go to Work 9-10pm	Go to Work 10-11pm
Go for Treatments	Go for Treatments N/A	Go for Treatments 2-3pm	Go for Treatments 3-4pm	Go for Treatments 4-5pm	Go for Treatments 5-6pm	Go for Treatments 6-7pm	Go for Treatments 7-8pm	Go for Treatments 8-9pm	Go for Treatments 9-10pm	Go for Treatments 10-11pm
Afternoon Tea Break	Afternoon Tea Break N/A	Afternoon Tea Break 2-3pm	Afternoon Tea Break 3-4pm	Afternoon Tea Break 4-5pm	Afternoon Tea Break 5-6pm	Afternoon Tea Break 6-7pm	Afternoon Tea Break 7-8pm	Afternoon Tea Break 8-9pm	Afternoon Tea Break 9-10pm	Afternoon Tea Break 10-11pm
Finish Working	Finish Working N/A	Finish Working 2-3pm	Finish Working 3-4pm	Finish Working 4-5pm	Finish Working 5-6pm	Finish Working 6-7pm	Finish Working 7-8pm	Finish Working 8-9pm	Finish Working 9-10pm	Finish Working 10-11pm
Exercise	Exercise N/A	Exercise 2-3pm	Exercise 3-4pm	Exercise 4-5pm	Exercise 5-6pm	Exercise 6-7pm	Exercise 7-8pm	Exercise 8-9pm	Exercise 9-10pm	Exercise 10-11pm
Dinner	Dinner N/A	Dinner 2-3pm	Dinner 3-4pm	Dinner 4-5pm	Dinner 5-6pm	Dinner 6-7pm	Dinner 7-8pm	Dinner 8-9pm	Dinner 9-10pm	Dinner 10-11pm
Relaxing	Relaxing N/A	Relaxing 2-3pm	Relaxing 3-4pm	Relaxing 4-5pm	Relaxing 5-6pm	Relaxing 6-7pm	Relaxing 7-8pm	Relaxing 8-9pm	Relaxing 9-10pm	Relaxing 10-11pm
Go to Sleep	Go to Sleep N/A	Go to Sleep 2-3pm	Go to Sleep 3-4pm	Go to Sleep 4-5pm	Go to Sleep 5-6pm	Go to Sleep 6-7pm	Go to Sleep 7-8pm	Go to Sleep 8-9pm	Go to Sleep 9-10pm	Go to Sleep 10-11pm

Should some of these activities take place in the morning, just mark them as N/A. Multiple times can be chosen for each activity.

How much exercise do you get? *

	None	Short Walks >10min	Long Walks <20min	Workout >30min	Workout <30min	Workout <60min
Monday AM	Monday AM None	Monday AM Short Walks >10min	Monday AM Long Walks <20min	Monday AM Workout >30min	Monday AM Workout <30min	Monday AM Workout <60min
Monday PM	Monday PM None	Monday PM Short Walks >10min	Monday PM Long Walks <20min	Monday PM Workout >30min	Monday PM Workout <30min	Monday PM Workout <60min
Tuesday AM	Tuesday AM None	Tuesday AM Short Walks >10min	Tuesday AM Long Walks <20min	Tuesday AM Workout >30min	Tuesday AM Workout <30min	Tuesday AM Workout <60min
Tuesday PM	Tuesday PM None	Tuesday PM Short Walks >10min	Tuesday PM Long Walks <20min	Tuesday PM Workout >30min	Tuesday PM Workout <30min	Tuesday PM Workout <60min
Wednesday AM	Wednesday AM None	Wednesday AM Short Walks >10min	Wednesday AM Long Walks <20min	Wednesday AM Workout >30min	Wednesday AM Workout <30min	Wednesday AM Workout <60min
Wednesday PM	Wednesday PM None	Wednesday PM Short Walks >10min	Wednesday PM Long Walks <20min	Wednesday PM Workout >30min	Wednesday PM Workout <30min	Wednesday PM Workout <60min
Thursday AM	Thursday AM None	Thursday AM Short Walks >10min	Thursday AM Long Walks <20min	Thursday AM Workout >30min	Thursday AM Workout <30min	Thursday AM Workout <60min
Thursday PM	Thursday PM None	Thursday PM Short Walks >10min	Thursday PM Long Walks <20min	Thursday PM Workout >30min	Thursday PM Workout <30min	Thursday PM Workout <60min
Friday AM	Friday AM None	Friday AM Short Walks >10min	Friday AM Long Walks <20min	Friday AM Workout >30min	Friday AM Workout <30min	Friday AM Workout <60min
Friday PM	Friday PM None	Friday PM Short Walks >10min	Friday PM Long Walks <20min	Friday PM Workout >30min	Friday PM Workout <30min	Friday PM Workout <60min
Saturday AM	Saturday AM None	Saturday AM Short Walks >10min	Saturday AM Long Walks <20min	Saturday AM Workout >30min	Saturday AM Workout <30min	Saturday AM Workout <60min
Saturday PM	Saturday PM None	Saturday PM Short Walks >10min	Saturday PM Long Walks <20min	Saturday PM Workout >30min	Saturday PM Workout <30min	Saturday PM Workout <60min
Sunday AM	Sunday AM None	Sunday AM Short Walks >10min	Sunday AM Long Walks <20min	Sunday AM Workout >30min	Sunday AM Workout <30min	Sunday AM Workout <60min
Sunday PM	Sunday PM None	Sunday PM Short Walks >10min	Sunday PM Long Walks <20min	Sunday PM Workout >30min	Sunday PM Workout <30min	Sunday PM Workout <60min

Any activity that is faster than walking that accelerates your heart rate for more that 10 minutes can be considered as a workout.

Do you have easy access to the following? *

Walking trail with natural surface
Park with grass or sand
Sports field with grass or sand
Beach with sand
Country fields
Gym
None of the above

Multiple answers is possible.

Do you smoke or vape? *

NO
Less than 10 cigarettes per day
10 - 20 cigarettes per day
20 -40 cigarettes per day
more than 40 cigarettes per day

Do you want to quit smoking? *

Do you consume alcohol? *

How regular do you consume alcohol? *

Daily
Week days only
Weekends only
Once a week
Once every two weeks
Once a month
One every 6 months

How much alcohol do you consume? *

	0 glasses	1 - 2 glasses	3 - 4 glasses	5 - 6 glasses	6+ glasses
Spirits	Spirits 0 glasses	Spirits 1 - 2 glasses	Spirits 3 - 4 glasses	Spirits 5 - 6 glasses	Spirits 6+ glasses
Liqueur	Liqueur 0 glasses	Liqueur 1 - 2 glasses	Liqueur 3 - 4 glasses	Liqueur 5 - 6 glasses	Liqueur 6+ glasses
Beer	Beer 0 glasses	Beer 1 - 2 glasses	Beer 3 - 4 glasses	Beer 5 - 6 glasses	Beer 6+ glasses
Ciders	Ciders 0 glasses	Ciders 1 - 2 glasses	Ciders 3 - 4 glasses	Ciders 5 - 6 glasses	Ciders 6+ glasses
Wine	Wine 0 glasses	Wine 1 - 2 glasses	Wine 3 - 4 glasses	Wine 5 - 6 glasses	Wine 6+ glasses

Do you want to quit drinking alcohol? *

Medication

Do you suffer from pain? *

Where is your pain? *

Head
Joints
Upper Spine
Lower Spine
Mouth & Throat
Chest
Breast
Intestines
Reproductive Organs
Skin
Nerves
Other

Multiple answers is possible.

Please describe your pain? *

Pain comes and goes throughout the day
Pain is constant
Mostly moderate pain without the need of medication
Can control the pain with medication
Medication only take the edge off the pain
Pain is like a stabbing knife, severe agonizing pain and gone in seconds
Pulsating pain

Pain Comments

Here you can describe your pain in more detail. This is optional.

What medication do you use? *

Pharmaceutical products
Natural products
Supplements
I don't use any medication

How much medicinal products do you take per day? *

	None	1 - 3 once a day	1 - 3 twice a day	3+ more than twice a day
Pharmaceutical products	Pharmaceutical products None	Pharmaceutical products 1 - 3 once a day	Pharmaceutical products 1 - 3 twice a day	Pharmaceutical products 3+ more than twice a day
Natural products	Natural products None	Natural products 1 - 3 once a day	Natural products 1 - 3 twice a day	Natural products 3+ more than twice a day
Supplements	Supplements None	Supplements 1 - 3 once a day	Supplements 1 - 3 twice a day	Supplements 3+ more than twice a day

An option is required in every line.

Please list the pharmaceutical products that you are using? *

Please ensure that the spelling and dosage are correct?

Please list the natural products that you are using? *

Please ensure that the spelling and dosage are correct?

Please list the supplement products that you are using? *

Please ensure that the spelling and dosage are correct?

Frequencial Evaluation

Each person's psyche is made up of different frequencies. These frequencies needs to be balanced equally. Music and external sounds or noise can disturb or balance these frequencies, affecting your mindset, your thoughts, your actions and your health. The body cannot heal itself properly if these frequencies are out of balance. These questions are designed to measure the energy frequencies in your body, also known as your Chakra. It is crucial that you answer these questions as accurate as possible as it will influence the balancing frequencies in the relaxation audio used in this protocol.

What types of music do you listen to regularly?

	Never	Once a month	Once a week	Often	Regularly
Blues	Blues Never	Blues Once a month	Blues Once a week	Blues Often	Blues Regularly
Classical	Classical Never	Classical Once a month	Classical Once a week	Classical Often	Classical Regularly
Country	Country Never	Country Once a month	Country Once a week	Country Often	Country Regularly
Electronic	Electronic Never	Electronic Once a month	Electronic Once a week	Electronic Often	Electronic Regularly
Folk	Folk Never	Folk Once a month	Folk Once a week	Folk Often	Folk Regularly
Gospel	Gospel Never	Gospel Once a month	Gospel Once a week	Gospel Often	Gospel Regularly
Hip-Hop	Hip-Hop Never	Hip-Hop Once a month	Hip-Hop Once a week	Hip-Hop Often	Hip-Hop Regularly
Instrumental	Instrumental Never	Instrumental Once a month	Instrumental Once a week	Instrumental Often	Instrumental Regularly
Jazz	Jazz Never	Jazz Once a month	Jazz Once a week	Jazz Often	Jazz Regularly
New Age	New Age Never	New Age Once a month	New Age Once a week	New Age Often	New Age Regularly
Rap	Rap Never	Rap Once a month	Rap Once a week	Rap Often	Rap Regularly
Reggae	Reggae Never	Reggae Once a month	Reggae Once a week	Reggae Often	Reggae Regularly
Rock	Rock Never	Rock Once a month	Rock Once a week	Rock Often	Rock Regularly

Do you find it easy to recall your dreams? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you work at your relationships being harmonious? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel connected to the universe and everything which is around you? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you a team player? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you tend to hide your emotions, keeping a poker face? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you very careful to whom you express your love, so as not to get hurt? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you find it so difficult to express the things you want and feel, that you talk little about that?* *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you a very emotional and passionate person? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you have such a strong will that you always dominate situations? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you always give so much love to others that you forget about yourself? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you, instead of being spontaneous, tend to prepare for situations by thinking about them? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you love most people? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Is your voice loud and clear? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you communicate well, balancing talking and listening? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel you really inhabit your body? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel a strong need to be emotionally connected to people? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you tend to be passive and indecisive in social situations? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you express yourself through some art form (music, painting, singing, etc) or other creative way? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you tend to be ashamed of your impulses? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you trust most people? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you self-confident? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you good at thinking in words, symbols and concepts? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel at home everywhere? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel comfortable with both intimacy and lust? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you generally feel free to act upon what you want? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you friendly by nature? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you aware of being the expression of something much bigger than yourself? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you always feeling secure? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you express your feelings freely, letting them flow without holding back? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you always able to be assertive when necessary? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

If you''re having a conflict with someone, are you considerate of that person's pain? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel nervous easily, or do you regularly avoid situations that might make you nervous? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you see everything that happens to you as lessons for you to learn? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel that coincidence is often meaningful and intended, and not random at all? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you communicate well in writing? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you tend to talk very much? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you creative? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you rely a lot on your intuition? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you good at developing insight? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you have a well-developed self-awareness? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you feel you can express your sexual feelings? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you have visions or premonitions? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you usually feel in control of the situation while in a group? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you able to extend an attitude of compassion to others and yourself easily? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you fantasize a lot? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you find it difficult to visualize things? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you always aware of your likes and dislikes, and your needs? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you worry about your financial situation or the safety of your home? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you often exercise self-restraint? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you often rely on the insight of someone else? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you always feel grounded, present and unshakable? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you accept everything that happens to you, surrendering yourself to life? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you withdrawn or lonely, or do you keep people at a distance? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you frequently have good, original ideas? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Are you quite attached to anyone or anything? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

Do you regularly avoid particular situations? *

	Not at all	Not really	Neutral	Yes	Definitely
	Not at all	Not really	Neutral	Yes	Definitely

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