Skin Gut iconsjiva Mind Body Soul Your Jivome 1. Most of the time my skin is Oily Both oily and dry Dry Neutral 2. Which of the following do you currently experience on your face or body? (Select all that apply) Pimples Dry or flaky skin Blackheads or whiteheads Redness or inflammation I don't experience any of these 2.1 How often do you get pimples? 3 or less times a month More than 3 times a month 2.2 How many pimples do you usually have? 5 pimples or less More than 5 pimples 2.3 Where do you get pimples? Face Body Both face and body 2.1 How often do you get dry or flaky skin? 3 or less times a month More than 3 times a month 2.2 How severe is your dry or flaky skin? Mild Moderate or severe 2.1 How often do you get blackheads or whiteheads? 3 or less times a month More than 3 times a month 2.2 How many blackheads or whiteheads do you usually have? 5 blackheads or whiteheads or less More than 5 blackheads or whiteheads 2.1 How often do you get redness or inflamed skin? 3 or less times a month More than 3 times a month 2.2 How severe is your redness or inflamed skin? Mild Moderate or severe 3. Do any of the following bother you on your face or body? (Select all that apply) Fine lines Wrinkles Dark spots Uneven skin tone Thin or crepey skin Cellulite None of the above How much do fine lines bother you on your face or body? A little bit Moderately A lot How much do wrinkles bother you on your face or body? A little bit Moderately A lot How much do dark spots bother you on your face or body? A little bit Moderately A lot How much does uneven skin tone bother you on your face or body? A little bit Moderately A lot How much does thin or crepey skin bother you on your face or body? A little bit Moderately A lot How much does cellulite bother you on your face or body? A little bit Moderately A lot 4. Which of the following is closest to your skin color? Turn your palm towards you and look at the color of the skin on your inner forearm 5. Have you noticed any of the following about your scalp or hair? (Select all that apply) Too frizzy Too dull Too oily or sweaty Too dry or flaky Too sensitive or inflamed Hair is too thin or thinning None of the above 6. Do any of the following bother you about your nails? (Select all that apply) Pits or ridges Brittle or peel Too thick Inflammation or puffiness around the nails I bite my nails None of the above 7. In terms of your digestion, which of the following do you usually experience? (Select all that apply) Constipation Loose stools or diarrhea Gas and bloating I typically have a normal digestion 8. How often do you experience heartburn? Never Rarely Sometimes Frequently Always 9. How much stress do you feel on an average day? Low Somewhat low Moderate Somewhat high High 10. How much anxiety do you feel on an average day? Low Somewhat low Moderate Somewhat high High 11. How well is your focus and concentration on a typical day? Poor Somewhat poor Neutral Good Very good 12. How quickly do you become irritated or angry? Never Rarely Sometimes Quickly Very Quickly 13. How many hours do you typically sleep per night? Less than 4 hours 4 to 6 hours 6 to 8 hours More than 8 hours 14. How rested do you usually feel after an average night’s sleep? Poorly rested Somewhat poorly rested Moderately rested Somewhat well rested Well rested 15. How quickly do you become mentally or physically tired? Never Rarely Sometimes Quickly Very Quickly 16. What are your main fitness goals? (Select all that apply) Lose weight Build muscle Improve cardio Improve flexibility Stay active 17. How do you typically make important decisions? Mostly with my heart and intuition Somewhat with my heart and intuition Equal heart and intuition AND head and intellect Somewhat with my head and intellect Mostly with my head and intellect 18. How quickly do you bounce back from setbacks and failures? Very Slowly Slowly Neither slowly nor quickly Quickly Very Quickly 19. Finally, tell us what you find important in your life. Please mark the three that are the most important factors to you? Education Fame Family Health Inner Peace Love Money Passion Purpose Self-Confidence 20. Which of the following are areas where you would like to grow? (Select all that apply) Emotional health Mental health Physical health Relationships Spirituality and Spiritual Growth 21. Tell Us About Your Food Preferences Dairy Free Gluten Free Grain Free Keto Paleo Vegan Vegeterian No Special Preferences Previous Next