Fasting History All information will remain confidential. OK Question Title * 1. Have you ever fasted before? Yes No OK Question Title * 2. If yes, why? OK Question Title * 3. If yes, when and for how long? When? How long? Dates: OK Question Title * 4. What did you consume while fasting? Check all that apply. Water Coconut Water Herbs Bone Broth Vegetable Broth Juices Green Vegetable Posts Fruit Juices OK Question Title * 5. Did you consume anything else? Please describe: OK Question Title * 6. What are your goals for this YouHealing Program? OK Question Title * 7. Physical Goals: OK Question Title * 8. Emotional Goals: OK Question Title * 9. Spiritual Goals: OK Question Title * 10. Other concerns and/or goals? OK DONE