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/AcuteNausea or vomiting01234Diarrhea01234Constipation01234Bloated feeling01234Belching or passing gas01234Heartburn01234Total - Digestive Tract*CommentsEars Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteItchy ears01234Earaches and ear infections01234Drainage from ear01234Ringing in ear, hearing loss01234Total - Ears*CommentsEmotions Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteMood swings01234Anxiety, fear or nervousness01234Anger, irritability or aggressiveness01234Depression01234Total - Emotions*CommentsEnergy / Activity Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteFatigue, sluggishness01234Apathy, lethargy01234Hyperactivity01234Restlessness01234Total - Energy/Activity*CommentsEyes Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteWatery or itchy eyes01234Swollen, reddened or sticky eyelids01234Bags or dark circles under eyes01234Blurred or tunnel vision (does not include near or far sightedness)01234Total - Eyes*CommentsHead Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteHeadaches01234Faintness01234Dizziness01234Insomnia01234Total - Head*CommentsLungs Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteChest congestion01234Asthma, bronchitis01234Shortness of breath01234Difficulty breathing01234Total - Lungs*CommentsMind Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcutePoor memory01234Confusion, poor comprehension01234Poor concentration01234Poor physical coordination01234Difficulty making decisions01234Stuttering or stammering01234Slurred speech01234Learning disabilities01234Total - Mind*CommentsMouth / Throat Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteChronic coughing01234Gagging, frequent need to clear throat01234Sore throat, hoarseness, loss of voice01234Swollen or discolored tongue, gums, lips01234Canker sores01234Total - Mouth/Throat*CommentsNose Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteStuffy nose01234Sinus problems01234Hay fever01234Sneezing attacks01234Excessive mucus formation01234Total - Nose*CommentsSkin Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteAcne01234Hives, rashes or dry skin01234Hair loss01234Flushing or hot flashes01234Excessive sweating01234Total - Skin*CommentsHeart Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteSkipped heartbeats01234Rapid heartbeats01234Chest pain01234Total - Heart*CommentsJoints / Muscles Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcutePain or aches in joints01234Arthritis01234Stiffness or limitation of movement01234Pain or aches in muscles01234Feeling of weakness or tiredness01234Total - Joints/Muscles*CommentsWeight Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteBinge eating/drinking01234Craving certain foods01234Excessive weight01234Compulsive eating01234Water retention01234Underweight01234Total - Weight*CommentsOther Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/AcuteFrequent illness01234Frequent or urgent urination01234Genital itch or discharge01234Total - Other*CommentsGrand 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 ProgressInclude emotions, physical changes, symptoms, etc. This is your space to keep a written record of your cleanse journey.