Name *

First Name

Last Name

Date

MM

DD

YYYY

Survey

I've been in bed and probably asleep before 10:30pm nightly

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have avoided all added sugar in my diet this week

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've exercised for 30 mins 3x this week

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My bedtime ritual included things that aided in my sleep

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've avoided saying YES to things that aren't healthy

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've stayed aware of toxins vs tonics in my daily life and chosen health over convenience

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've taken all of my supplements this week

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I'm hydrating well with an electrolyte drink such as LMNT (2-3 packs daily)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've avoided grains in my diet (breads, crackers, pasta, tortillas)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I've prayed and/or meditated on Optimizing myself daily

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree