The Clear™ Cleanse Quiz

The Clear Cleanse Quiz

Fill out all fields based on your progress since the last time you filled out the quiz.

Please complete this form in one sitting. Incomplete forms cannot be saved.
Name*
First Last
Email*
Date of Birth*
Month
Day
Year
Today's Date*
Month
Day
Year
What brought you here?
What are your main health concerns at this time?
What is working?
What would you like to improve?
What are your next step actions/goals?
Digestive Tract
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Nausea or vomiting
Diarrhea
Constipation
Bloated feeling
Belching or passing gas
Heartburn
Total – Digestive Tract*
Comments
Ears
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Itchy ears
Earaches and ear infections
Drainage from ear
Ringing in ear, hearing loss
Total – Ears*
Comments
Emotions
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Mood swings
Anxiety, fear or nervousness
Anger, irritability or aggressiveness
Depression
Total – Emotions*
Comments
Energy / Activity
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total – Energy/Activity*
Comments
Eyes
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near or far sightedness)
Total – Eyes*
Comments
Head
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Headaches
Faintness
Dizziness
Insomnia
Total – Head*
Comments
Lungs
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total – Lungs*
Comments
Mind
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total – Mind*
Comments
Mouth / Throat
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total – Mouth/Throat*
Comments
Nose
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total – Nose*
Comments
Skin
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Acne
Hives, rashes or dry skin
Hair loss
Flushing or hot flashes
Excessive sweating
Total – Skin*
Comments
Heart
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Skipped heartbeats
Rapid heartbeats
Chest pain
Total – Heart*
Comments
Joints / Muscles
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total – Joints/Muscles*
Comments
Weight
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Total – Weight*
Comments
Other
Rate on a scale of 0 to 4 – 0 = Never and 4 = Often/Acute
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total – Other*
Comments
Grand Total*
Body Comp Measurements (in inches)
Bust
Chest
Waist (below chest and just above navel)
Hips (around mid buttocks)
Mid Upper Left Thigh
Mid Upper Right Thigh
Mid Upper Right Arm
Mid Upper Left Arm
Above Left Knee
Above Right Knee
Right Calf (widest part)
Left Calf (widest part)
Stomach
Weight in pounds
Journal Your Progress
Include emotions, physical changes, symptoms, etc. This is your space to keep a written record of your cleanse journey.

The Clear Cleanse Quiz

Please complete this form in one sitting. Incomplete forms cannot be saved.

Digestive Tract

Ears

Emotions

Energy / Activity

Eyes

Head

Lungs

Mind

Mouth / Throat

Nose

Skin

Heart

Joints / Muscles

Weight

Other

Body Comp Measurements (in inches)

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