Complete Program Registration Estimated Time: 20 minutes Number of Sections: 6This 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 HealthPlease answer the following question to the best of your ability:Do you have any heart/cardiovascular issues?---NoYesAre you currently pregnant or breast-feeding?---NoYesAre you considered overweight?---NoYesList any current health issues you currently have (in order of importance):Health ProblemDuration1---Less then 1 year1-2 years2-5 years+5 years2---Less then 1 year1-2 years2-5 years+5 years3---Less then 1 year1-2 years2-5 years+5 years4---Less then 1 year1-2 years2-5 years+5 years5---Less then 1 year1-2 years2-5 years+5 years Section 2 - LifestyleThe 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+ timesHow many hours per day do you sleep?---4-6 hours7-8 hours8+ hoursDo you smoke cigarettes?---NoYesDo you believe you have a problem with alcohol consumption?---NoYesHow hours of your day are spent sitting?---Less then 1 hour1-2 hours2-4 hours4-6 hours6-8 hours8+ hoursHow many hours of your day is spent on relaxation?---Less then 30 minutes30min-1 hour1-2 hours2+ hoursDo you get anxious in social situations?---NoYesDo you practice any form of regular meditation?---NoYesDo you have difficulties getting to sleep?---NoYesHow active are you in your daily routine (walking, moving around, etc.):---LazyMove around time to timeModerately activeExtremely active Section 3 - Dietary HabitsLet'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?---NoYesDo you have any confirmed food allergies?---NoYesHow many serving of vegetables do you consume daily?---1-2 servings3-4 servings5-6 servings6+ servingsPrimary source of protein?---Red meatPoultryEggsMilkFishNutsOtherWhat 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 VitaminsZincIronOtherDo you take any specific vitamin or mineral supplements for your deficiencies?---NoYesDo you take multivitamin supplements?---NoYesAre you currently taking any home remedies or herbal supplements?---NoYesAre you currently on any special diet?---NoYesAre you a vegetarian?---NoYesDo you read food labels and inspect the majority of food you consume?---NoYes Section 4 - Skin SpecificsLet's take a moment to analyze a few aspects specific to your skin:What skin condition(s) do you currently believe your facing?Seborrheic DermatitisAcneRosaceaPsoriasisPeriorial DermatitisEczemaOtherNot SureHow long have you had your skin condition?---Less then 1 year1-2 years3-5 years5+ yearsPlease select which facial regions present the most difficulties?ChinEyebrowsNasal creasesNoseForeheadCheeksEatsEye lidsOtherUpload 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+ timesDo you use facial cleanser or soap to wash your face?---CleanserSoapNeitherHow often do you inspect your skin in the mirror?---Very rarelySometimesOnce dayMultiple times per dayDo you currently use any products containing corticosteroids and if so, how often?---Don't useFew times per weekOnce a dayMultiple times per dayHow long is your history with corticosteroid usage?---Never usedLess then 1 year1-2 years2+ Years Section 5 - SupplementaryThese 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 oldWould you consider yourself overweight?---NoYesPlease 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 breathHow ready are you to commit to change?---Extremely readyReadySo soFind it difficultNot readyDo you have 15 minutes a week to dedicate to the community?---YesMost likelyToo busyNot sureIs there any additional information you would like to share? Section 6 - Contact InformationThis 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.