1. Of your current diet, estimate what % is fresh, raw/ uncooked vegan foods?
---
99/100
95
90
80
70
60
50
40
30
20
10
<10
2. How long have you consumed a primarily raw vegan diet? Indicate months or years.
3.
4.
5. *
---
6. Before making any positive lifestyle changes, approximately how often did you experience the common cold per year? *
---
7. What is your dietary goal of fresh raw/uncooked vegan foods?
---
99/100
95
90
80
70
60
50
40
30
20
10
<10
8. If you still consume some cooked food, how often?
---
Daily
Monthly
Yearly/holidays
When traveling
In cold weather
Never
9. In what forms?
10. If you find yourself going off of the raw diet, what are the reasons you do so?
11. Did you first attempt to embrace a vegetarian or vegan diet before discovering raw foods?
---
NO
YES
12. If yes, were you successful?
---
NO
YES
13. How long did you eat that way before going raw?
---
<6 months
<1 year
1 year
2 years
3
4
5
6
7
8
9
10
>10
>12
>15
>20
14. Was there a serious health problem that lead you to improve your lifestyle?
---
NO
YES
15. If so which one(s)?
16. Has this condition cleared up as a result of your lifestyle changes?
---
Completely
Some improvement
No change
17. Indicate changes in the following conditions related to dietary improvements using a scale from one to ten, with one being much worse, 5 no change, and 10 complete rejuvenation. Heart problems:
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
18. Vision problems
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
19. Respitatory disorders, asthma, pnemonia
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
20. Sinus problems, allergies
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
21. Joint pain, arthritis
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
22. Digestive disorders
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
23. Insomnia
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
24. Skin problems
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
25. Muscle tightness
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
26. Headaches
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
27. Mental illness
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
28. Menstrual/reproductive problems
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
29. Sugar metabolic disorders
---
Never had
Much worse
Worse
No change
Improved
Completely rejuvenated
30. Have you experienced a change in your weight? How much?
---
Desired gain
Desired loss
Undesired gain
Undesired loss
No change
31. Stop and take a deep breath before continuing!
32.
33.
---
0
1
2
3
4
5
6
7
8
9
10+
34. Now how often do you experience the common cold?
---
0
1
2
3
4
5
6
7
8
9
10+
35. Do you currently take prescription drugs?
---
NO
YES
36. Have you taken them anytime in the past 5 years?
---
NO
YES
37. How has your consumption changed since making positive lifestyle changes?
---
Increased
Decreased
Stayed the same
38. Do you currently take over the counter medication?
---
NO
YES
39. Have you anytime in the past five years?
---
NO
YES
40. Has your consumption been influenced by adopting a raw food diet?
---
Increased
Decreased
Stayed the same
41. Do you consume recreational drugs currently?
---
NO
Yearly
Monthly
Weekly
Daily
42. If yes has your consumption changed since adopting a raw diet?
---
Increased
Decreased
Stayed the same
43.
44. Do you smoke cigarettes
---
NO
YES
45. Have you in the past five years?
---
Yes, regularly
Yes, occasionally
No, I quit after going raw
No, I have never smoked
46. If yes has your consumption:
---
Increased
Decreased
Stayed the same
47. Do you currently drink alcohol?
---
YES, occasionally
YES, regularly
NO, I stopped after changing my diet.
NO, I never drank much anyhow.
48. If yes has your consumption changed since improving your diet?
---
Inceased
Decrease
Stayed the same
49. Do you currently consume caffeine (coffee, tea, soda, chocolate, etc.)
---
YES, regularly
YES, occasionally
NO, quit when I went raw
NO, I never had a regular caffine habit
50. If yes, has your coffee consumption been affected by your change in diet?
---
Decreased
Increased
Stayed the Same
51. Sit straight, belly breathing, through the nose
52. Do you currently consume refined sugars?
---
NO
YES
53. Have you consumed refined sugar in the past five years?
---
NO
YES
54. Has your consumption of refined sugar been affected by changing your diet?
---
Decreased
Increased
Stayed the same
55. For the next series of questions average your consumption for the past year. If you would eat something but super rarely put 1 or 2 %. Of your current diet estimate by calories what % is meat, chicken, or fish:
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
56. dairy and eggs:
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
57. beans (include sprouted)
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
58. grain products (include sprouted/dehydrated)
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
59. nuts and seeds (include nut butters and tahini
0%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
60. root vegetables:
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
61. leafy green vegetables (include green sprouts):
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
62. sea vegetables:
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
63. fatty fruits (avocado, durian, young coconut)
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
64. Non-sweet fruits (tomato, cucumber)
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
65. All other fruits
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
100%
66. Approximately what % of your diet is organically grown?
0%
1%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
95%
100%
67. What % is locally grown?
0%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
95%
100%
68. What % do you grow or harvest yourself? Include sprouting.
---
0%
2%
5%
7%
10%
15%
20%
30%
40%
50%
60%
70%
80%
90%
95%
100%
69. Where do you live?
---
Rural
Small town
Suburban area
Urban- small city
Urban- large city
70. Which climate do you live in?
---
Tropical
Sub-tropical
Mild (rarely freezes)
Northern (snow/subfreezing in winter days in a row)
Artic
Migrate
Travel throughout the year
71. If northern how does your diet change with the seasons?
72. Do you eat oils? Include cold pressed oils such as olive, flax, and coconut.
---
Not to my knowledge
Daily
Weekly
Monthly
Yearly
73. Do you eat cured olives?
---
Daily
Weekly
Monthly
Yearly
No
74. Do you use added salt in your food?
---
Daily
Weekly
Monthly
Yearly
Not to my knowledge
75. Has your use of salt changed as you stay on a raw diet?
---
Decreased
Increased
Stayed the same
76. Do you include stimulating spices such as garlic, onion, mustard seeds, or hot peppers in your diet?
---
Daily
Weekly
Monthly
Yearly
Not to my knowledge
77. Has your use of spices changed?
---
Increased
Decreased
Stayed the same
78. Do you include fresh pressed/extracted juices other than citrus in your regular diet?
---
NO
YES
79. How many times do you eat in a typical day?
---
0
1
2
3
4
5
6
7
8
9
10
I graze throughout the day
80. About how many foods do you include in a typical meal? (include salt, spices, and different varieties of fruits and vegetables each as a separate food) Morning meals?
---
0
1
2
3
4
5
6
7
8
9
10
>10
81. mid-day?
---
0
1
2
3
4
5
6
7
8
9
10
>10
82. Evening?
---
0
1
2
3
4
5
6
7
8
9
10
>10
83. Do you take any of the following supplements?
84. Has your use of supplements changed since adopting a raw diet?
---
Increased
Decreased
Stayed the same
85. How often do you experience the following? Anger?
---
Never
Rarely
Seldom
Occasionally
Usually
Always
86. Depression?
---
Never
Rarely
Seldom
Occasionally
Usually
Always
87. Confusion:
---
Never
Rarely
Seldom
Occasionally
Usually
Always
88. A sense of well-being
89. Feeling of connection
---
Never
Rarely
Seldom
Occasionally
Usually
Always
90. Distraction/Inability to concentrate
---
Never
Rarely
Seldom
Occasionally
Usually
Always
91. Inclination to meditate
---
Never
Rarely
Seldom
Occasionally
Usually
Always
92. Belief in God/ higher power
---
Never
Rarely
Seldom
Occasionally
Usually
Always
93. Peace
---
Never
Rarely
Seldom
Occasionally
Usually
Always
94. Suicidal thoughts
---
Never
Rarely
Seldom
Occasionally
Usually
Always
95. Love
---
Never
Rarely
Seldom
Occasionally
Usually
Always
96. Bliss/Ecstasy
---
Never
Rarely
Seldom
Occasionally
Usually
Always
97. Violent feelings/ behaviors
---
Never
Rarely
Seldom
Occasionally
Usually
Always
98. Gratitude
---
Never
Rarely
Seldom
Occasionally
Usually
Always
99. Have you ever felt very close to a powerful, spiritual force that seemed to lift you out of yourself?
---
NO
YES
100. Have you ever had a moment of sudden spiritual/religious awakening or insight?
---
NO
YES
101. According to ancient scriptures there are five classifications of the mind. Please rate yourself honestly.
102. If you practice any form of yoga or meditation please complete the following section: How many years have you practiced yoga or other spiritual discipline?
---
Less than one
1
2
3
4
5
6
7
8
9
10
15
20
>20
103. Indicate which style/s you mainly practice:
104. How many days a week on average do you practice?
---
0
1
2
3
4
5
6
7
105. How long do you practice on an average day?
---
10 min
20 min
30 min
45 min
1 hour
2 hours
3 hours
4 hours
5 hours
other
106. Do you include any of the following in your regular routine?
107. Have you noticed your ability to stick with your chosen dietary patterns improved by consistent practice?
---
NO
YES
108. How much does what you eat affect the quality of your practice?
---
Don't notice a difference
Very little
Somewhat
Quite a bit
If I eat certain foods my mind becomes so unsettled I am unable to concentrate to practice
109. Has your practice brought to awareness any specific food sensitivities/allergies?
