Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Have you ever fasted before? *

Yes

No

Overall how would you rate your current physical fitness and health? *

Poor

Fair

Good

Very Good

Excellent

Are you under the care of a medical professional for a current condition? *

Yes

No

If yes, have you discussed your participation in this program with him/her?

Yes

No

Are you currently taking any medications? *

Yes

No

Are you currently under the care of, or have ever seen a mental health professional? *

Yes

No

Do you have or have you ever had any blood sugar problems? *

Yes

No

Overall how would you rate your current mental health and general attitude to life? *

Generally depressed

Sometimes feel good/sometimes feel depressed

Generally feel good/sometimes get down

Generally feel very good

I always feel excellent

I can swing from feeling really good/excellent to being depressed/sad.