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Your Intake Questionnaire

Welcome! Here’s your 10-Day Detox Intake Questionnaire

It is wonderful that you are participating in the 10-Day Detox Program designed to kick sugar cravings to the curb, balance your metabolism and your blood sugar levels, reduce cravings shed a few pounds, and get you on track for 2020.

All information will be kept confidential.


Please complete the following questions to help me understand your current health status, food sensitivities and lifestyle preferences. Email this back to me when you have completed it.


Are you satisfied with your current health status?


What are your goals for the 10-Day Detox Program?


What is your motivation for seeking out a detox program?


If you had a magic wand what would you change about your health?


Do you practice any stress management techniques? If so, tell me about them.


Do you exercise? When, what and how often?


Do you have any food sensitivities? What are they?


Have you followed a detox program before? If so tell me about that experience.

Do you want to see changes in your body weight or composition?


Do you have any inflammatory conditions, if so tell me about them.


Do you experience any chronic pain? If so, tell me about it.


What are your health, lifestyle and dietary goals?


Thank you! I look forward to seeing you in the 10-Day Program!



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