Equilibrium Diet Questionnaire – Equilibrium Diet



Your Name (required)

Your Email (required)

Marital Status:


Weight (pounds):

Waist (inches):

Clothing Size (pants for men, dress for women):

Hours of exercise per week:

Hours of TV per week:

Diabetic (I or II):

What % of your hair is grey?

# of fast food items/week:


Yes or No When Observing Yourself on the following (type Y for yes, N for no)
White Coated Tongue
Toenail Fungus
Spit in glass of water upon waking in the morning

# of Alcoholic Drinks/week:

# of times you have taken an antibiotic in the last 2 years:

Number of times you use any OTC drug or cream per week:

Number of times you take any prescription medicine per week (for example, if you take two different prescription medications 2x/day then your total would be 7 days*2*2pills = 28).

Please list the OTC and prescription medications you take:

On a scale from 0-10, how much do you agree with each of the following statements (0=disagree completely, 5= nutral or neither agree nor disagree, 10=agree completely).

I am happy
I am distressed
My stress level is high
I am at peace
I love and accept myself
I love and accept others
I judge or criticize myself often
I am a perfectionist
I judge or criticize others often
I have thoughts running through my head all the time
I like drama/gossip
I am fearful
I am an emotional shopper, tv watcher, worker or eater
I am responsible for myself and my life
I am responsible for other people's actions and reactions
Others cause me to react in certain ways
I choose my actions at all times
I am safe at all times
I know who I am and what I want
I often feel lost and confused about my purpose in life
I relate to other people easily
I have social anxiety

Have you had an experience that you would consider spiritual? If so and you are willing to share, please do.

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