Healthy Habits Survey: October 2017

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* 1. Please take a few moments to find out if your habits are leading you to a healthier body in the future or not. Once your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?

I agree

I do not agree

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* 2. What is your Name and Surname?

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* 3. Which Skin Renewal branch is your home branch?

Brooklyn

Bedfordview

Claremont

Cape Quarter

Constantia

Fourways

Durban

Hillcrest

Irene

Illovo

Morningside

Parkhurst

Stellenbosch

Umhlanga

Willowbridge

West Rand

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* 4. Please select your Gender?

Male

Female

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* 5. Please select Yes or No for the following questions.

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* 6. How many hours do you sleep each night?

4 or fewer hours

About 5-6 hours

About 7-8 hours

9 or more hours

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* 7. Do you have your hormones checked regularly?

Yes

Why should I do this?

	Yes	No
Do you try to eat a low calorie diet?	Do you try to eat a low calorie diet? Yes	Do you try to eat a low calorie diet? No
Do you consciously avoid sweets and junk food?	Do you consciously avoid sweets and junk food? Yes	Do you consciously avoid sweets and junk food? No
Do you seek out organic food rather than conventional food?	Do you seek out organic food rather than conventional food? Yes	Do you seek out organic food rather than conventional food? No
Do you do everything your medical doctor tells you?	Do you do everything your medical doctor tells you? Yes	Do you do everything your medical doctor tells you? No
Do you research your health subjects online?	Do you research your health subjects online? Yes	Do you research your health subjects online? No
Are you overweight because you don't exercise?	Are you overweight because you don't exercise? Yes	Are you overweight because you don't exercise? No
Are you on chronic medication?	Are you on chronic medication? Yes	Are you on chronic medication? No
Do you eat in moderation?	Do you eat in moderation? Yes	Do you eat in moderation? No
Do you eat breakfast?	Do you eat breakfast? Yes	Do you eat breakfast? No
Do you filter your water before consuming it?	Do you filter your water before consuming it? Yes	Do you filter your water before consuming it? No
Do you seek out more natural or organic body care products?	Do you seek out more natural or organic body care products? Yes	Do you seek out more natural or organic body care products? No
Do you use anti-perspirant?	Do you use anti-perspirant? Yes	Do you use anti-perspirant? No
Do you get a flu shot every year?	Do you get a flu shot every year? Yes	Do you get a flu shot every year? No
Do you carry your cell phone on your body? (On hip or in your pocket)	Do you carry your cell phone on your body? (On hip or in your pocket) Yes	Do you carry your cell phone on your body? (On hip or in your pocket) No
Do you have Wi-Fi on in your house 24/7?	Do you have Wi-Fi on in your house 24/7? Yes	Do you have Wi-Fi on in your house 24/7? No
Do you use insect repellent inside your house?	Do you use insect repellent inside your house? Yes	Do you use insect repellent inside your house? No
Do you spray your lawn for weeds/fertilizer?	Do you spray your lawn for weeds/fertilizer? Yes	Do you spray your lawn for weeds/fertilizer? No
Do you eat a high protein diet?	Do you eat a high protein diet? Yes	Do you eat a high protein diet? No
Do you try to keep your calories or food choices the same everyday?	Do you try to keep your calories or food choices the same everyday? Yes	Do you try to keep your calories or food choices the same everyday? No
Does your house or basement have any sign of mould?	Does your house or basement have any sign of mould? Yes	Does your house or basement have any sign of mould? No
Do you take a baby aspirin (half a Disprin) everyday to thin your blood?	Do you take a baby aspirin (half a Disprin) everyday to thin your blood? Yes	Do you take a baby aspirin (half a Disprin) everyday to thin your blood? No
Do you take supplements that contain dyes for colour?	Do you take supplements that contain dyes for colour? Yes	Do you take supplements that contain dyes for colour? No
Do you avoid all supplements and herbs, because we should be able to get our nutrients from our food?	Do you avoid all supplements and herbs, because we should be able to get our nutrients from our food? Yes	Do you avoid all supplements and herbs, because we should be able to get our nutrients from our food? No
Do you believe your genetics cause health problems and there is nothing you can do about it?	Do you believe your genetics cause health problems and there is nothing you can do about it? Yes	Do you believe your genetics cause health problems and there is nothing you can do about it? No
Do you choose artificial sweeteners over regular sugar?	Do you choose artificial sweeteners over regular sugar? Yes	Do you choose artificial sweeteners over regular sugar? No
Do you use unrefined sea salt over regular table salt?	Do you use unrefined sea salt over regular table salt? Yes	Do you use unrefined sea salt over regular table salt? No
Do you purchase fluoride toothpaste, because fluoride is good for your teeth?	Do you purchase fluoride toothpaste, because fluoride is good for your teeth? Yes	Do you purchase fluoride toothpaste, because fluoride is good for your teeth? No