'ASK Life Clarity | Well Being | Participant Information

All information provided by you will be treated as highly confidential. Please fill in all questions to help us understand and serve you better | Team Ask Life Clarity

Dear Participant

Let us start by expressing our deepest Gratitude for giving us the opportunity to live our Purpose through supporting your Mind and Body to be and act in their Highest Potential.

Please help us serve you better by taking a couple of minutes to tell us about your current health and mind set. We appreciate your time and faith in us and we will make sure we meet and exceed  your expectations.

Love & Light


Team Ask Life Clarity


Every Meal!At least once a DayAt least once a weekRarelyNever
Fried Food
Fast Foods
Rich or Spicy Foods
Sweets / Deserts
Baked Items
Dairy Products (Milk, Cheese ice-cream, yoghurt etc)
Ready to Cook Food
More than 3 Cups / GlassesLess than 3 Cups / GlassesDon't Drink at AllToo Much to even Count!
Black Coffee / Expresso
Fresh Fruit Juices
Canned / Packaged Juices
Aerated Drinks
Energy Drinks
Sugar Free Drinks
Alcoholic Beer
Hard Liquors / Other Alcoholic Drinks
AgreeSomewhat AgreeNot Sure Somewhat DisagreeDisagree
When Hungry?
From Frustration?
To be Sociable?
From Habit / Conditioning?
Due to Peer Pressure?
To Avoid Acidity / Health Issues?
To be healthy?
For the Taste of Food?
Don't Really Know!
3 M/A/N2 M/N1 DailyWhen neededEmergency only
Blood Pressure
Oral Contraceptives
Insulin / Blood Sugar Pills
Pain Killers
Heart based Pills
Hormonal Pills / Drugs
Cancer Drugs
Sleeping Pills
Vitamins & Supplements
Laxatives Chemical
Laxatives Natural
Homeopathy Medicines
Ayurvedic Medicines
Unani Medicines
Anti Allergens
AddictionHabitualFrequent UseCausal about itCurious Not Used by ChoiceNot Tried Yet
Tobacco Smoking
Beer & Wine
Tobacco Chewing
Drugs - Marijuana
Drugs - Cocaine/Heroin/Opium
Drugs - Psychedelic
Drugs - Prescription Pain Killer
Drugs - Prescription Antidepressant
Drugs - Prescription Sleeping Pills
Drugs - Prescription Others
Over night Sleep
Rest & Relaxation
Gym / Exercise
Breathing Exercise
Screen Time (Phone laptop etc)
Eating while watching TV/Phone
Holidays (Relaxation)
Holidays (Fun)
Weekend Binge Eating
Weekend Binge Drinking (Alcohol)
Sports / Games
Sitting at a Desk
Standing at Work
Nap during day
Severe / FrequentModerate / WeeklyMild / Occasionally Never Occurred
Tiered all the time
Hungry between meals & at night
Fearful / Overwhelmed by people places situations
Magnify relatively smaller issues
Junk Food Consuption
Crave for Sugary Aerated drinks / snacks between meals
Alcohol Consumption
Drink more than 3 Cups of Tea / Coffee
Lack of Energy
Can't work under pressure
Can not Concentrate
Poor Memory
Worry Frequently
Low Self Image
Highly emotional
Sensitive / can cry easily
Fits of Anger
Headaches / Migraines
Sleepy during day
Drowsy after meals
Can not get started in the morning
Eat when nervous
Fatigue relived by eating
Fatigue relived by Sleeping / Resting
Get shaky inside when Hungry
Suicidal thoughts / tendencies
Bad dreams / nightmares
Cold sweaty hands / feet
Hot Flushes at Night
Hot Flushes during the Day
Trembling Hands
Bruise easily
Bleeding Gums
Tooth decay / enable thinning
Disturbed motor-control
Losing Balance on sudden movement
Muscle twitching
Muscular cramps / Stiffness
Lower Back Pain
Shoulder Blades Pain
Full Back Pain
Pain in Buttocks area
Leg Cramps / Restlessness
Frequent Urination
Nervousness / Cramps in Stomach
Asthma Hay Fever Rashes
Irritable before meals
Feel Faint if Meal is delayed
Ulcers / Gastric / Chronic Acidity
Indigestion / Bloating
Blurred Vison
Dizziness / Giddiness / Light Headedness
Aware of Breathing Heavily
Excessive Sweating
Excessive Thirst
Drastic weight Change
Anxiety / Panic Attacks
Excessive focus on cleanliness
Fear of germs / infection
When things are not organised creates scarcity

We sincerely appreciate your time and efforts and we are committed to your well being and growth. We will take your inputs into consideration while supporting you to heal rejuvenate and take charge of Your Life!

If you have any comments or concerns please Contact: 

Team Ask Life Clarity | you@asklifeclarity.com

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