Please complete each section to the best of your ability. Check those things that you do in your

life on a regular basis. Today, you can assess your own lifestyle and better understand if your

lifestyle is toxic free.

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 (includes coaching).

The survey will take about 15 minutes on average. By completing this form, you agree to be

added to our mailing list which you can opt out of at any time.

First Name *

Last Name *

Email *

Phone *

I eat mostly Organic foods or sustainably produced *

True

False

Other

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

True

False

I eat mostly Whole Foods *

True

False

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

True

False

I drink 6-8 glasses of water a day

True

False

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

True

False

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

True

False

My tap water is filtered *

True

False

I drink mostly bottled water *

True

False

Other

I filter my shower water *

True

False

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)

True

False

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

True

False

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

True

False

I am caffeine free *

True

False

I cook with aluminum foil *

True

False

Other

I cover my food in aluminum foil *

True

False

Does your home or work space have mold? *

True

False

If You answered Yes to the last question which area has the mold ? *

Home

Work

Other

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

True

False

Other

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

True

False

Other

Do you have chronic pain? *

Yes

Other

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

Did you Know That Stress and Pain Shrink Your Brain? *

Yes

Other

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

Yes

Other

Have you ever had a brain injury, concussion, TBI, Brain Tumor or something else? *

Yes

Other

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

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

Yes

Other

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

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

Have you ever had a test get to the root problem and provide solutions? *

Yes, I have. It was amazing.

No, I have not and would like to learn more

No I have not, but I don't believe in that

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

Congratulations. If you want to learn about how to live toxic free you can schedule a meeting *

Yes! Count Me In! :)

Thank you - I am good!

Other

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