Full Of Life, Vegan Connections
Plant-Based or Vegan?
In the Spotlight
Personal Juice Cleanse Assessment Form
Please describe any previous experience with juicing.
Please list your top 3 health and wellness goals.
Please outline any medical conditions you currently have.
What ideal results would you like to see at the end of your juice cleanse?
What's your current height and weight?
How healthy would you consider yourself?
Not healthy at all.
I'm okay but could use a lot of improvement.
I feel quite good but could use some improvement.
How often do you drink caffeine?
Once a day
More than once a day
Do you smoke?
What is your exercise style like?
I don't exercise.
I walk, take the stairs when I can, and like to be active in my daily life.
I make time to exercise at least a couple times a week.
I try to exercise daily.
Please check any conditions that may apply to you.
Blood sugar swings
Candidiasis (yeast overgrowth)
Irritable Bowel Syndrome
General skin problems
Please choose the option which best describes your diet.
Omnivore- eats meat and animals based foods at most meals
Omnivore- eats meat and animal based foods daily
Omnivore- eats meat and animal based foods sometimes but emphasizes plant based foods as well
Vegetarian- eats no land meat but eats fish, dairy and eggs
Vegetarian- eats no animals but eats dairy and egges
Vegetarian- sometimes eats dairy and eggs but mainly plant based foods
Vegan- eats no animal based foods but consumes processed foods
Vegan- eats no animal based foods and puts a strong emphasis on plant based whole foods
Do you experience food cravings or emotional eating? Please describe.
Do you have any obligations/ trips/ social events happening in the near future?
Do you have any specific concerns or fears about juice cleansing?