Lifestyle Assessment Form

All Three Images Are Different Versions Of Me

Rev. Jodi L. Suson-Calhoun

On My Journey Back To Health

Your Lifestyle Information

Please complete each section to the best of your ability. Check those things that you do in your life on a regular basis. Today, you can assess your own lifestyle and better understand if your lifestyle is toxic free.

Suson Essentials offers individual coaching sessions. We also offer the Emotional Healing Toxic Free Living Functional Food Program. It is perfect for those that want to reclaim their health. We offer the Self-Paced Program (no coaching), The Personal Coaching Program and the Family Coaching Program (includes coaching).

The survey will take about 15 minutes on average. By completing this form, you agree to be added to our mailing list which you can opt out of at any time.

* Please provide your email address

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* Please provide your First and Last Name

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* Please provide your best phone number

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* I eat mostly Organic foods or sustainably produced

True

False

Other

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I eat mostly conventional foods (not organic or responsibly produced, i.e, has pesticides and growth homones)

True

False

* I eat mostly Whole Foods

True

False

* I eat mostly Processed Foods like boxed food, pizza, Soda/pop pasta, cereal, cookies, ( more 50%)

True

False

* I drink 6-8 glasses of water a day

True

False

* I drink less than 6-8 glasses of water a day

True

False

* My tap water is filtered

True

False

* My tap water is not filtered - I drink from the tap

True

False

* I drink mostly bottled water

True

False

Other

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* I filter my shower water

True

False

* I consume high amounts of cane sugar - more than 30 grams a day (e.g., average can of pop/soda has 37 grams of sugar)

True

False

* I consume sugar substitutes that are plant based e.g., honey, monk fruit, stevia, agave

True

False

* I consume sugar substitutes that are synthetic , *e.g., equal, splenda, Sweet N' Low

True

False

* What is your dietary preference(s)?

Gluten Free

Dairy Free

Vegan

Vegetarian

Paleo

Keto

Pescatarian

No specific style

Other

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* I am caffeine free

True

False

* Let's Learn About Your Alcohol Consumption

1 drink a week

2-3 drinks a week

4-5 drinks a week

I don't drink

Other

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* I cook with aluminum foil

True

False

Other

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* I cover my food in aluminum foil

True

False

* Does your home or work space have mold?

True

False

* If You answered Yes to the last question which area has the mold ?

Home

Work

Other

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* We all live with stress, do you believe you live with "chronic" stress at home?

True

False

Other

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* We all live with stress, do you believe you live with "chronic" high stress at work?

True

False

Other

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Using a scale of 1- 5, How stressful is your life?

Less Stress

More Stress

* Do you believe that you live by your highest values most of the time

All the time

90% of the time

70% of the time

50% of the time

10% of the time

Never

Other

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* On a scale of 1 -5 How sad do you feel most of the time?

Hardly ever

Most of the time

* Do you have chronic pain?

Yes

Other

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* If you have pain, Where do you have pain? Put N/A if it does not apply

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* What do you do to manage your emotions (anger, stress, grief) Check all that apply to you

Prayer

Walk

Yoga

Meditation

Drink Alcohol

Eat More Than I Think I need

Dance or Sing

Garden

Cry

Listen to Music

Use a PEMF device or Sound Healing Device

Drink More Water

Take OTC pain killers

Smoke Cigarettes

Smoke Marijuana

Take Vitamins and Herbs /Essentials Oils

Use Prescription Drugs

Seek a Mental Health Counselor

Talk With Friends

Yell

Other

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* Did you Know That Stress and Pain Shrink Your Brain?

Yes

Other

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* Do You Know that your brain Is responsible for how you feel?

Yes

Other

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* Have you ever had a brain injury, concussion, TBI, Brain Tumor or something else?

Yes

Other

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If You answered Yes to the brain Injury, please share when it happened, how it happened and the steps you took to help yourself. Please put N/A if not applicable

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* Do you believe your are responsible for your own health?

Yes

Other

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* EMF Exposure - Please check all that apply to you

I use LED lightbulbs

I use Halogen Lightbulbs

I use a microwave for my food

I use a convection over for my food

I put my phone on Airplane Mode before bed

I turn off my wi-fi at night before bed

I leave the electronics outside the bedroom (tv, cellphones, computers)

I neutralize EMF in the home

I neutralize EMF for my body

I neutralized EMF in my car

I neutralize EMF for my phone

I have smart meters on my outside walls

I use a hairdryer

I use baby monitors

* Please help me understand what you use for personal care items. Check all that apply

I use aluminum free deodorant

I use fluoride free dental products. * e.g., toothpaste and mouthwash

I use toothpaste and mouthwash with Fluoride

I use plant based make up e.g., lipstick, cover up, eyeliner, eye shadow, mascara

I use plant based soap

I use plant based shampoo and conditioner

I use nail polish with out formaldehyde

I use plant based hair spray etc.

I color or treat my hair with chemicals

I use soap with endocrine disruptors (e.g., with BPA's PFA's , PCBs and Phalates)

I do not treat my hair with chemicals

Other

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* Please Help Me Understand Your Household Items. Please Check All That Apply

I use clorox or other bleach in the home

I use commercial window cleaners in the home e.g., Pledge, Windex, and Scrubbing Bubbles

I use chemical based dish soap

I use plant based dish soap

I use chemical based Dishwasher soap

I use plant based Dishwasher Soap

I use plant based wood cleaner

I use chemical based wood cleaner ( e.g., lemon pledge)

I use essential oils to clean the house

I use plastic hangers

I use metal hangers

I use wooden hangers

I use Round up for gardening

Other

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* What is the most important thing(s) that you want to change for yourself right now? Please list the top 3 only

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* Have you ever invested in yourself? (self help courses, plant based healing, coaching)

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* On a scale of 1 - 5 how coachable are you ?

Not coachable

Very Coachable

* Have you ever had a test get to the root problem and provide solutions?

Yes, I have. It was amazing.

No, I have not and would like to learn more

No I have not, but I don't believe in that

* What is the most important thing(s) that you want to change for yourself right now? Please list the top 3 only

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* Congratulations. If you want to learn about how to live toxic free you can schedule a meeting

Yes! Count Me In! :)

Thank you - I am good!

Other

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