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Fasting Questionnaire - Dry Fasting Club
This Questionnaire should be filled out each day of your dry fast. Ideally at Noon, but specific time not required.
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email
*
Your answer
What day of the dry fast are you on?
*
1
2
3
4
5
6
7
8
9
What is your blood glucose level? (in mg/dL)
*
Your answer
What is your blood ketone level?
*
Your answer
What is your body temperature?
*
Your answer
What is your heart rate (resting)?
*
Your answer
What is your blood pressure (if available)?
*
Your answer
Have you lost weight since starting the fast? If so, how much?
*
Your answer
How is your sleep quality?
*
Full out insomnia
1
2
3
4
5
6
7
8
9
10
Zero problems
Did your sleep improve, worsen, or stay the same?
*
improved
worsened
stayed the same
How many hours are you sleeping each night, on average?
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Your answer
What is your urine output frequency
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Not peeing
1
2
3
4
5
6
7
8
9
10
Peeing often and a lot
How thirsty do you feel?
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No thirst
1
2
3
4
5
6
7
8
9
10
Extreme thirst
Are you experiencing hunger?
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No hunger
1
2
3
4
5
6
7
8
9
10
Extreme hunger
Are you experiencing any physical symptoms (e.g., headache, dizziness)? If so, what?
*
Your answer
Do you feel lightheaded or dizzy when standing up?
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No
1
2
3
4
5
6
7
8
9
10
Very
Are you experiencing any muscle cramps or physical discomfort?
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1
2
3
4
5
6
7
8
9
10
Have you noticed any changes in body odor or breath?
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Your answer
Have you experienced any digestive discomfort?
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None
1
2
3
4
5
6
7
8
9
10
A lot of discomfort
Are you noticing any change in your sweating patterns?
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No sweating
1
2
3
4
5
6
7
8
9
10
A lot of sweating
How is your mental clarity
*
No clarity / brain fog
1
2
3
4
5
6
7
8
9
10
Amazing clarity
How are your energy levels
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No energy
1
2
3
4
5
6
7
8
9
10
Lots of energy
Are you experiencing any memory issues or difficulty concentrating?
*
Your answer
What is your emotional resilience or response to stress?
*
No stress
1
2
3
4
5
6
7
8
9
10
Extremely stressed
How is your mood overall?
*
Terrible
1
2
3
4
5
6
7
8
9
10
Amazing
Have you noticed any emotional changes or insights since starting the fast?
*
Your answer
Are you having any spiritual experiences?
*
None
1
2
3
4
5
6
7
8
9
10
Deeply spiritual / meditative
Have you exercised or done any physical activity? If so, describe briefly.
*
Your answer
Have you experienced any visual changes?
*
Blurred vision
1
2
3
4
5
6
7
8
9
10
Very improved vision
Have you experienced any auditory changes?
*
Dampened hearing
1
2
3
4
5
6
7
8
9
10
Very improved hearing
Have you experienced any changes in skin health?
*
Your answer
Have you noticed any improvement in joint pain, muscle stiffness, or inflammation?
*
None
1
2
3
4
5
6
7
8
9
10
Very improved
Have you noticed any changes in your sense of taste or smell?
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None
1
2
3
4
5
6
7
8
9
10
Very improved / heightened
Have you observed any other notable changes, benefits, or challenges since starting the fast?
*
Your answer
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