Cleanse & Glow Interest Survey 
This is a general wellness survey for all who are interested in joining the 30 day Cleanse & Glow wellness challenge. This is a private and non-judgemental survey that will only be shared to Jasmine and Caesar in preparation for the upcoming challenge this will help us to assist you in this highly vibrational journey to cleanse, reset, and charge the body. 

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First Name
Last Name
Email Address
Phone Number
Have you ever participated in a cleanse that lasts longer than 3 days? *
How often do you consume fruits and vegetables in your daily meals?
 *
Are there any specific foods or food groups you avoid or limit in your diet? If yes, please specify.
On average, how many hours of uninerrupted sleep do you get per night? 
 *
On a scale of 1 to 10, how satisfied are you with your sleep quality?
 *
Very dissatisfied
Very satisfied
Do you engage in regular physical activity or exercise? If yes, how many times per week?
 *
Which types of physical activity do you most enjoy?
Please specify any other activity you enjoy that is not listed:
On average, how many cups (8oz) of water do you consumer per day?
 *
On average, how many cups of caffeinated beverage do you consumer per day? *
Do you consume alcohol weekly? *
How often do you practice relaxation techniques or mindfulness exercises to manage your mental well-being?
 *
How would you rate your overall wellness on a scale of 1 to 10, considering physical, mental, and emotional aspects? *
not to great
excellent
Do you have any specific concerns or issues regarding your mental health that you would like to address?
With support, would you be willing to participate in cleanse that lasts longer than 3 days? *
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