Your Lifestyle Information

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Please complete each section to the best of your ability. Check those things that you do in your life on a regular basis.

Suson Essentials offers individual coaching sessions. We also offer the Emotional Healing Toxic Free Living Functional Food Program. It is perfect for those that want to reclaim their health. We offer the Self-Paced Program (no coaching), The Personal Coaching Program and the Family Coaching Program.

Today, you can assess your own lifestyle and better understand if your lifestyle is toxic free.

The survey will take about 15 minutes on average.

Email *

What is Your First and Last Name *

What is your address? *

What Is Your Phone number *

Lifestyle Questions - food and water - please check all that apply to you. *

16 points

I eat mostly Organic foods or sustainably produced

I eat mostly conventional foods (not organic or responsibly produced, i.e, has pesticides and growth homones)

I eat mostly Whole Foods

I eat mostly Processed Foods like boxed food, pizza, Soda/pop pasta, cereal, cookies, ( more 50%)

I drink 6-8 glasses of water a day

I drink less than 6-8 glasses of water a day

My tap water is filtered

My tap water is not filtered - I drink from the tap

I drink mostly bottled water

I filter my shower water

I consume high amounts of cane sugar - more than 30 grams a day (e.g., average can of pop/soda has 37 grams of sugar)

I consume sugar substitutes that are plant based e.g., honey, monk fruit, stevia, agave

I consume sugar substitutes that are synthetic , *e.g., equal, splenda, Sweet N' Low

I am gluten free

I am dairy free

I am caffeine free

I drink alcohol beverages 1 x a week (1 drink)

I drink alcohol beverages more than 3 x a week (3 drinks)

I do not drink alcohol

I am vegan

I am vegatarian

I am pescatarian

I eat KETO style

I eat Paleo Style

I don't have a style of eating

I cook with aluminum foil

I cover my food in aluminum foil

Other:

Required

Does your home or work space have mold? *

1 point

Yes

Don't Know

We all live with stress, do you believe you live with "chronic" stress at home? *

1 point

Yes

Maybe

We all live with stress, do you believe you live with "chronic" high stress at work? *

1 point

Yes

Maybe

Not Applicable

Other:

Using a scale of 1- 10, How stressful is your life? 1 is less stress and 10 is the most stress. *

1 point

low

High

Do you believe that you live by your highest values most of the time? *

1 point

Yes

Maybe

I am a work in progress

On a scale of 1 -10 How sad are you? *

1 point

Not Sad at all

Very Sad

What do you do to manage your stress levels? Check all that apply to you. *

1 point

Pray

Walk

Run

Yoga

Meditation

Drink alcohol

Eat more food than I need

Dance

Garden

Cry

Sing

Listen to Music

Use a PEMF device

Use Sound Therapy

Drink More water?

Use over the counter pain killers or something like that?

Smoke Cigarettes

Smoke Weed

Take vitamins and herbs

Use prescription drugs

Use Essential Oils

I see a mental health counselor

I talk with my friends

I yell

Other:

Required

Did you know that stress shrinks your brain? *

1 point

Yes

Do You Know that your brain Is responsible for how you feel? *

1 point

Yes

Did You Know That Pain Shrinks Your Brain *

1 point

Yes

Have you ever had a brain injury? Concussion, Traumatic Brain Injury, Brain Tumor or something else? *

1 point

Yes

If You answered Yes to the brain Injury, please share when it happened, how it happened and the steps you took to help yourself. Please put N/A if not applicable *

1 point

Do you believe your are responsible for your own health? *

1 point

Yes

Maybe

Lifestyle Questions - EMF - Please check all that apply to you. *

8 points

I use LED lightbulbs

I use Halogen Lightbulbs

I use a microwave for my food

I use a convection over for my food

I put my phone on Airplane Mode before bed

I turn off my wi-fi at night before bed

I neutralize EMF in the home

I neutralized EMF in my car

I neutralize EMF for my body

I neutralize EMF for my phone

What is EMF

What is 5G

I have smart meters on my outside walls

I use a hairdryer

I use baby monitors

Other:

Required

How do you manage Anger? Please check all that apply to you. *

1 point

I go for a walk

I go for a run

I talk it out

I pray

I talk with friends

I eat

I drink alcohol

I use over the counter medications

I use prescription drugs

I use essential oils

I use nutrition

I use food as medicine

I see a mental health counselor

I use PEMF

I use precision sound therapy

I listen to music

I avoid work and life

I garden

I cook

I yell

I journal

Required

How do you manage grief ? Please check all that apply to you.

1 point

I cry

I walk

I run

I do yoga

I pray

I take over the counter medications

I smoke weed

I use essential oils

I see a mental health counselor

I drink alcohol

I over eat

I use food as medicine

I dance

I work more hours than needed

I avoid work and life

I garden

I cook

I sleep more

I yell

I use precision sound therapy

I use PEMF

I journal

Other:

Required

Do you have chronic pain? *

1 point

Yes

If you have chronic pain, how do you presently manage the pain? *

1 point

Over the counter drugs

Breathe work

Prayer

Meditation

Prescription Meds

Essential Oils

Vitamins , herbs and amino acids

Not applicable

Required

If you have pain, Where do you have pain? Put N/A if it does not apply. *

1 point

Lifestyle - Personal Care Items

8 points

I use aluminum free deodorant

I use fluoride free dental products * e.g., toothpaste and mouthwash

I use toothpaste and mouthwash with Fluoride

I use plant based soap

I use plant based make up e.g., lipstick, cover up, eyeliner, eye shadow, mascara

I use plant based shampoo and conditioner

I use nail polish with out formaldehyde

I use plant based hair spray etc.

I color or treat my hair with chemicals

I use soap with endocrine disruptors (e.g., with BPA's PFA's , PCBs and Phalates)

I do not treat my hair with chemicals

Other:

Lifestyle - Household Items *

7 points

I use clorox or other bleach in the home

I use commercial window cleaners in the home e.g., Pledge, Windex, and Scrubbing Bubbles

I use chemical based dish soap

I use plant based dish soap

I use chemical based Dishwasher soap

I use plant based Dishwasher Soap

I use plant based wood cleaner

I used chemical based wood cleaner ( e.g., lemon pledge)

I use plant based floor cleaner

I used chemical based floor cleaner

I use essential oils to clean the house

I use wooden hangers

I use plastic hangers

I use metal hangers

I use Round up for gardening

Other:

Required

What is the most important thing(s) that you want to change for yourself right now? Please list the top 3 only *

1 point

Have you had a nutrient deficiency blood test in the last 3 years? *

1 point

Yes

Have you ever invested in yourself? (self help courses, plant based healing, coaching) *

1 point

Yes

On a scale of 1 - 10 how coachable are you ? 1 is not coachable and 10 is most coachable? *

1 point

Congratulations. If you want to learn about how to live toxic free you can schedule a meeting Schedule a Free Consult about the Functional Food Program
*

1 point

Yes I would love to schedule a free consult using the link above.

No, My lifestyle is awesome. Thank you anyway!

Other:

A copy of your responses will be emailed to the address you provided.

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