Complete Program Registration Estimated Time: 20 minutes Number of Sections: 6 This is the complete program registration form. It is meant to serve as a general evaluation tool and improve your program. You can skip questions you don't feel comfortable answering. However, the detail of your submission will have a direct impact the direction of the program. Section 1 - General Health Please answer the following question to the best of your ability: Do you have any heart/cardiovascular issues?---NoYes Are you currently pregnant or breast-feeding?---NoYes Are you considered overweight?---NoYes List any current health issues you currently have (in order of importance): Health ProblemDuration 1---Less then 1 year1-2 years2-5 years+5 years 2---Less then 1 year1-2 years2-5 years+5 years 3---Less then 1 year1-2 years2-5 years+5 years 4---Less then 1 year1-2 years2-5 years+5 years 5---Less then 1 year1-2 years2-5 years+5 years Section 2 - Lifestyle The following questions will evaluate various aspects of your lifestyle, please answer as accurately as possible: How many times per week do your exercise?---0 times1-2 times3-4 times5-7 times7+ times How many hours per day do you sleep?---4-6 hours7-8 hours8+ hours Do you smoke cigarettes?---NoYes Do you believe you have a problem with alcohol consumption?---NoYes How hours of your day are spent sitting?---Less then 1 hour1-2 hours2-4 hours4-6 hours6-8 hours8+ hours How many hours of your day is spent on relaxation?---Less then 30 minutes30min-1 hour1-2 hours2+ hours Do you get anxious in social situations?---NoYes Do you practice any form of regular meditation?---NoYes Do you have difficulties getting to sleep?---NoYes How active are you in your daily routine (walking, moving around, etc.):---LazyMove around time to timeModerately activeExtremely active Section 3 - Dietary Habits Let's focus our attention to your food habits and see if there are any areas for improvement: Do you believe you have any food allergies or sensitivities?---NoYes Do you have any confirmed food allergies?---NoYes How many serving of vegetables do you consume daily?---1-2 servings3-4 servings5-6 servings6+ servings Primary source of protein?---Red meatPoultryEggsMilkFishNutsOther What percentage of your dietary intake comes from packaged foods?---10-20%21-30%31-60%61-100% How often do you eat or take out from a fast food restaurant?---10-20%21-30%31-60%61-100% Check any vitamin or mineral deficiencies you believe you may have:Vitamin EVitamin CVitamin DVitamin AB VitaminsZincIronOther Do you take any specific vitamin or mineral supplements for your deficiencies?---NoYes Do you take multivitamin supplements?---NoYes Are you currently taking any home remedies or herbal supplements?---NoYes Are you currently on any special diet?---NoYes Are you a vegetarian?---NoYes Do you read food labels and inspect the majority of food you consume?---NoYes Section 4 - Skin Specifics Let's take a moment to analyze a few aspects specific to your skin: What skin condition(s) do you believe you're currently facing?Seborrheic DermatitisAcneRosaceaPsoriasisPeriorial DermatitisEczemaOtherNot Sure How long have you had your skin condition?---Less then 1 year1-2 years3-5 years5+ years Please select which facial regions present the most difficulties?ChinEyebrowsNasal creasesNoseForeheadCheeksEatsEye lidsOther Upload a photo of your skin (good quality close up recommended): In as few words as possible describe your skin issues: How many times a day do you wash your face?---Never1 time2-3 times3+ times Do you use facial cleanser or soap to wash your face?---CleanserSoapNeither How often do you inspect your skin in the mirror?---Very rarelySometimesOnce dayMultiple times per day Do you currently use any products containing corticosteroids and if so, how often?---Don't useFew times per weekOnce a dayMultiple times per day How long is your history with corticosteroid usage?---Never usedLess then 1 year1-2 years2+ Years Section 5 - Supplementary These questions help to uncover other potential factors which may be playing a role: What age category do you fall into:---0-7 years old8-16 years old17-25 years old26-40 years old41-60 years old60+ years old Would you consider yourself overweight?---NoYes Please check any symptoms that you have experience on an regular basis:Heartburn or acid refluxFeel bloated after eatingAsthma, sinus infections or stuffy noseWhite coating on the tongueDifficulties passing stoolBad breath How ready are you to commit to change?---Extremely readyReadySo soFind it difficultNot ready Do you have 15 minutes a week to dedicate to the community?---YesMost likelyToo busyNot sure Is there any additional information you would like to share? Section 6 - Contact Information This information will be used for follow up contact: First Name: Last Name: Email address: Thank for taking the time to fill your questionaire.You can expect to recieve an initial response within 2-3 days.