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Cancer Freedom Assessment

Tell me more about where you are in your journey!

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Question 1 of 12

What type of cancer did you or do you have?

Question 2 of 12

Is the cancer: 

A

In the process of doing chemo/radiation/surgery

B

Already did chemo/radiation/surgery

C

Have a diagnosis but have not done any chemo/radiation/surgery

D

Am wanting to prevent getting cancer

Question 3 of 12

What strategies have you used to address your diagnosis?

Question 4 of 12

Three greatest obstacles to making changes - pick three

(Select all that apply)
A

Lack of family support

B

Lack of money

C

Not enough time

D

Too tired

E

Don’t know how

F

Don’t want to go against the grain

G

Don’t have a guide

H

Need accountability

I

Not motivated enough

Question 5 of 12

Have you ever done any functional testing? If so, what showed up?

Question 6 of 12

List your current typical diet for one day.

Question 7 of 12

List the current symptoms that are bothering you.

Question 8 of 12

Check any of these symptoms and/or diagnosis you have

(Select all that apply)
A

Autoimmune condition

B

Candida

C

Osteoporosis/Osteopenia

D

Eczema

E

Brain Fog

F

Mood Swings

G

Depression

H

Arthritis

I

Migraines

J

Lyme Infection

K

Anxiety

L

Breast Implants

M

Pre/Diabetes

N

Poor Digestion

O

Reflux/Heartburn

P

Bloated/Gassy

Question 9 of 12

Checklist of potential toxins

(Select all that apply)
A

Exposure to mold

B

Amalgams in your mouth

C

Drinking unfiltered water

D

Using commercial cosmetics/toiletries

E

Using commercial detergents

F

Using air fresheners

G

Using non-stick pans

H

Frequent swimming in chlorinated pools

I

Smoking or 2nd hand smoke

J

Tick bites

K

Wifi in your house and place of work

Question 10 of 12

Do you know of any trauma or stresses that hurt your heart in the year or so leading up to diagnosis?

Question 11 of 12

What are you hoping to achieve? What would your life look like in a year if everything turned out the way you’d like?

Question 12 of 12

Are you financially able to dig into finding out why you got cancer in the first place?

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