Welcome to your Cancer Questionnaire Your Name Your Email Your Phone Number. Please include your Country Code. What State and Country are you currently located in? 9. Feeling blue or worthlessness? Not at All A little Moderately Quite a bit Extremely None Congratulation for Choosing the MUST BRILLIANT PROGRAM that will SAVE YOUR LIFE! Feel excited because You WILL BECOME a NEW PERSON and have a NEW LIFE! You are here because there is an imbalance in your body, mind or Soul, so be grateful, because IT is YOUR WAKE UP CALL, an opportunity to START LIVING!The FIRST THING TO DO, IS to LET GO OF FEAR Because YOU WILL BE OK AND IN a VERY SHORT period of time!! At the end of the journey, YOU WILL BE NEW PERSON. YOU WILL SEE YOURSELF LOOKING YOUNGER, GORGEOUS, and FELLING WONDERFUL!At Becoming Excellence, we believe that people who come to us for help, whether, CANCER or acute health condition or lack of meaning and purpose in life. Instability in our relationships, the environment we live or work will imbalance our health too. Whichever is the case, we ensure consideration for "all parts," conscious that all other body parts will not work correctly if one body part is not functioning well, because an imbalance of one area will affect the body's overall's health. SO LETS FOUND OUT WHAT IS THE CORE OF YOUR IMBALANCE! 1. Cancer Questions None 1. What type and stage of cancer were you told you have? 2. When was the date of diagnosis? 3. Please check which one of the following test the have done on you? Magnetic resonance imaging (MRI) Computerized tomography (CT) scan Positron emission tomography (PET) scan Ultrasound and X-ray Biopsy Complete blood count (CBC) 4. When do you need to arrange for treatment? Please select your answer ASAP Next 30 days Next 60 days 5. Have you think of what inbalanced you? What may be the cause of your cancer? 6. What do you do for work? Please describe the stress levels. 2. Your Nature None 7. What is your data of birth? Please enter your exact date of birth, day, month, year, and the city your born. The exact time you come to this world. If you don't know the time right now, Please don't forget to send that later. Be mindful that it is critical information for you. 3. Your Mind None 8. How often is your mind anchored in the present moment? All the time Most of the time Some of the time Rarely Never None 9. How often are you grateful? All the time Most of the time Some of the time Rarely Never None 10. Feeling suddenly scared for no reason? Nervousness or shakiness inside? Not at All A little Moderately Quite a bit Extremely None 11. Spells of terror or panic? Your worry too much? Not at All A little Moderately Quite a bit Extremely None 12. I like taking part in exciting and noisy parties Not at All Yes, a little Moderately Quite a bit Very Often None 13. To escape routine life, I need something beyond the existing excitement. Not at All Yes, a little Moderately Quite a bit Very often None 14. How often do you feel stressed? Not at All Yes, a little Some of the time Very often All the time None 15. What do you consider the main source of your stress? Work Family/Friends Medical Medical Relationship Issues or Status Other (please specify) N/A None 16. How often do you feel anger? Not at All Yes, a little Some of the time Very often All the time None 17. What do you consider the main source of your anger? Work Family/Friends/Love Health Finances Inner Thoughts Other N/A. None 18. How often do you feel Happy? Not at All Yes, a little Some of the time Very often All the time None 19. What do you consider the main source of your happiness? Work Family/Friends/Love Financial Inner Feelings Other .N/A None 4. Your Body None 20. What activities do you do for fun or relaxation and how many times/week? Meditation Deep breathing Art/music Cooking Reading Travel Volunteer work 21. Do you exercise and how many times per week? 0 1 -3 4 times or more None 22. Please specify type of exercise Biking Dance Running Walking Weight training Other 23. Do you have trouble sleeping? All of the time Most of the time Some of the time Rarely Never Other None 24. In the past 2 weeks do you experience any pain or disconfort? if yes please describe what and where : 25. Besides the cancer diagnosis, have you had OR do you presently have any other medical condition? If yes, please list them. 26. List the medications you are presently taking. 5. Your Nutrition None 27. How many cups of coffee or caffeinated beverages do you normally consume daily? 0 -3 4 -6 7 or more None 28. How many 8 oz. glasses of water do you normally drink daily? 0 -2 3 -6 6- 8 9 or more None 29. How much-fried foods do you eat? All of the time Most of the time Some of the time Rarely Never None 30. Are you getting 3-5 servings of fruits and vegetables/day? yes No None 31. In general how do you feel about your nutritional habits? 32. How often do you take Omega 3? Rarely Some of the time Most of the time All of the time None 33. What are your levels of vitamin D and How often do you take it? 34. Do you know your levels of Magnesium? How often do you eat high magnesium content foods like oats, sunflower seeds? 35. How often do you eat high Iodine content foods like seaweeds or seafoods? Rarely Some of the time Most of the time All of the time None 6. Your Habits None 36. Do you smoke? If yes, how many years? 37. Do you drink? If yes, how many drinks a week? 38. What of the following do you like to do more? Watching TV Social Media Video Games Gambling Other 39. Do you procrastinate? Yes No None 7. Your Relationships None 40. What's your current relationship status? Married Engaged In a relationship Single None 41. How long have you and your partner been in a relationship? Please select your answer Less than a 1 year 1- 3 years 3 - 5 years 5 -10 years More than 10 years Hint 42. How would best describe your relationship? He/She brings the best of me Uplifting Satisfaying Restrictive Stressful Other Hint 43. In terms of time, effort, money, attention etc...do you feel that? Please select your answer You invest more than your partner Your partner invest more than you. You both invest the same amount Hint 44. How do you rate your communication in terms of Frequency, constructiveness, and honesty? Excellent Good It could be better Frustrating Poor None Hint 45. What do you think is trigering the problem? Hint 46. Who else is in your support system? 7. Your Finances None 47. In few words how are your finances? 48. What financial behaviors are your weakness (check all that apply). I keep track of my expenses on a regular basis. I put money aside for savings, future purchases, or emergencies. I pay my credit card bills on time each month and am almost never later. I prepare a budget every month. I make goals about how to spend money and I discuss them with my family. I feel secure in my current financial situation. 7. Manisfeting Power None 49. From 1 to 10. 10 as the highest. How strong is your faith? 50. What are your expectations when you finish the program? Time's up
