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Emotional Readiness
Please answer the following questions to the best of your knowledge.
Enter your full name
*
Enter your email
*
On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:
To take nutritional supplements
*
To take nutritional supplements
1
2
3
4
5
Not willing
Very willing
To engage in any type of physical activity/exercise regularly
*
To engage in any type of physical activity/exercise regularly
1
2
3
4
5
Not willing
Very willing
To meditate daily
*
To meditate daily
1
2
3
4
5
Not willing
Very willing
To keep a record/food diary of everything that you eat
*
To keep a record/food diary of everything that you eat
1
2
3
4
5
Not willing
Very willing
To modify your lifestyle habits
*
To modify your lifestyle habits
1
2
3
4
5
Not willing
Very willing
Rate your stressors based on the following factors:
Work
*
Work
1
2
3
4
5
6
7
8
9
10
Low
High
Family
*
Family
1
2
3
4
5
6
7
8
9
10
Low
High
Social Life
*
Social Life
1
2
3
4
5
6
7
8
9
10
Low
High
Financial life
*
Financial life
1
2
3
4
5
6
7
8
9
10
Low
High
Health
*
Health
1
2
3
4
5
6
7
8
9
10
Low
High
Is your family supporting you in the healing journey?
*
Is your family supporting you in the healing journey?
A
Yes
B
No
Who prepares the meal for you?
*
What is your biggest challenge/hurdle?
*
Submit
