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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.

  • Digestive Tract

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Ears

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Emotions

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Energy / Activity

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Eyes

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Head

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Lungs

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Mind

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Mouth / Throat

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Nose

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Skin

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Heart

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Joints / Muscles

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Weight

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Other

    Rate on a scale of 0 to 4 - 0 = Never and 4 = Often/Acute
  • Body Comp Measurements (in inches)

  • Include emotions, physical changes, symptoms, etc. This is your space to keep a written record of your cleanse journey.