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Blindspots & Breakthroughs Questionnaire

This life-changing questionnaire takes about 15 minutes to complete. The 60+ questions will illuminate your health blind spots.

Please answer all of the questions. Each response has a point value. As you answer the questions, write down the points for each of your answers, then total your points for each section. When you submit the form, you'll see a points chart to show you which aspects of your health are likely out of balance and need your attention.

You'll also have the option to schedule a free call with Greg to interpret your results.

Your first name

What's your email?

Your age?

What's your height and current weight?

QUICK OVERVIEW

What is your main reason for seeking help with your health and/or fitness right now? In other words, what's your main challenge and your main goal?

In which part(s) of your life do you feel you most need a breakthrough? (multiple answers ok)

How urgent is your need to change?

A
B
C
D

Please list any medical conditions that you've been diagnosed to have

Please list any medications you're currently taking

Please list any history of chronic illness in your family (e.g. diabetes, heart disease, mental health, etc)

DIET (Begin keeping track of your points now)

How much of your food intake is processed -- that is, from a package, can, box, or fast food?

A
B
C
D

Overall, how much of your diet is organic?

A
B
C
D

What is your total intake of fruits and vegetables in your diet?

A
B
C
D

How many glasses of water do you drink daily?

A
B
C
D

What type of water do you drink?

A
B
C
D

How many cups of caffeinated beverages do you drink daily?

A
B
C
D

How many alcoholic drinks do you drink in a week?

A
B
C
D

How many sweets do you consume daily? (candy, pastries, sweetened drinks, etc)

A
B
C
D

How often do you eat store-bought salad dressings, cereals, or baked goods?

A
B
C

Please list any vitamins or supplements that you take regularly

HORMONE HEALTH

In recent years, would you say you've gained, maintained, or lost muscle mass?

A
B
C
D

How often do you feel irritable or fatigued?

A
B
C
D

How would you describe your general physical energy level?

A
B
C

If you are female, do you have significant symptoms of PMS, menopause, or other hormone-related issues? Please describe briefly if so (no points assigned for this question)

Have you experienced significant hair loss or unexplained weight changes in recent years?

A
B
C

How would you describe your libido or sex drive?

A
B
C

Do you have trouble with temperature regulation? (feeling too hot or too cold)

A
B
C

Do you experience chronic pain in any part of your body? If so, please describe (no points assigned)

How consistenly do you plan downtime, recovery time, self-care time into your weekly schedule? ("me time" when you can be alone, naps, hot baths, massages, "unproductive" time, reading for pleasure, etc)

A
B
C
D

EMOTIONAL AND MENTAL HEALTH

How regularly do you practice self-awareness rituals (journaling, therapy, meditation)?

A
B
C
D

How much "shadow work" have you done to release trapped emotions or shift subconscious beliefs?

A
B
C
D

Do you notice repeated patterns in your romantic life, finances, or physical health?

A
B
C

How ready and willing are you to look at painful experiences in your past or present?

A
B
C
D

Do you have a history of battling with depression or anxiety?

A
B
C
D

How would you describe your daily interaction with loved ones in the last few years or months?

A
B
C
D

How would you describe your worklife dynamics?

A
B
C
D

How much deliberate and regular effort do you give to creating and maintaining healthy boundaries in your personal and/or professional life?

A
B
C

GUT HEALTH

How often do you experience lower abdominal bloating or discomfort?

A
B
C
D

For you, is bloating & gas more likely caused by a high-fiber meal like broccoli and brown rice or by lots of sweets and bread products? (no poitns assigned)

A
B

Do you frequently have loose stools or diarrhea?

A
B
C
D

How often do you experience constipation?

A
B
C
D

Have you ever been diagnosed with IBS or leaky gut?

A
B

How often do you crave foods like bread, chocolate, sugary fruits or red meat if you've not had them in a while?

A
B
C
D

Have you ever taken a cycle of oral antibiotics?

A
B
C

Do you ever have heartburn or indigestion?

A
B
C
D

ENERGY LEVELS AND CIRCADIAN RHYTHM

How would you rate your daily energy level?

A
B
C
D
E

Do you often feel tired, even after a full night's sleep?

A
B
C
D

Do you travel across time zones frequently?

A
B
C

What time do you usually go to bed and wake up? (no points assigned)

Do you often wake up between 1am and 4am and have trouble falling back asleep?

A
B
C
D

After lunch, do you often feel drowsy and want to take a nap?

A
B
C
D

How good are you with time management, meeting deadlines, and being on time

A
B
C
D

PARASITES AND SYSTEMIC FUNGUS

Do you eat sushi?

A
B
C

Do you have pets now or in the recent past?

A
B

How stressful is your life overall?

A
B
C
D

Do you have a history of recurring yeast infections, athlete's foot, or other fungal issues?

A
B
C

Do you have frequent cravings for sugar, bread products, and/or dairy?

A
B
C
D

Do you experience itching in the ears, nose, or rectum?

A
B
C
D

Do you sometimes have rashes or unexplained skin issues?

A
B
C

FITNESS AND PHYSICAL ACTIVITY

Do you currently exercise regularly? (Yes= 0 pts, Sometimes=5 pts, No=10 pts) Please explain your workout type and how often:

How would you describe your current fitness level?

A
B
C
D

How active is your life overall?

A
B
C
D

How much do you care about and actively maintain good posture and form when you walk, sit, stand, and exercise?

A
B
C
D

How much of your total time, energy, and action each day is directed towards maintaining and cultivating your health?

A
B
C
D

HEALTH AND FITNESS GOALS

If you've tried but failed to change in the past, what got in the way?

What about Greg (the Planet Doctor) or his approach makes you feel open to his help and guidance?

Why MUST you change now? (why is staying in your current condition no longer an option?)

NOW ADD UP YOUR TOTAL POINTS FROM EACH SECTION AND THEN SUBMIT