EndoBoss® Academy -Part 1 - Foundation Program Opening Questionnaire
Please go through this Opening Questionnaire form and complete the check list and tick the symptoms that currently apply to you or you are suffering from. There is a box below to add in any other issues that are not listed. There is no right or wrong way to complete this form, but it is designed to monitor the progress and improvements throughout Part 1 and first 12 Weeks AND refer back to in 12 months time. Enjoy!
Date
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Month
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Day
Year
Date
Date of Starting
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Month
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Day
Year
Date Picker Icon
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
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Area Code
Phone Number
Mobile Number
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E-mail
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Skype Address
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Date of Birth
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How Many Years Have You Been In Your Current Relationship (If in one)?
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Please Share Your First Time & Age That You Became Aware Of Pelvic Pain & Bad Periods
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You may wish to put down any memories of the first time you felt frightened or scared or confused by the pain and what was happening in your body.
Age
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Occupation
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Relationship Status
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Married, Divorced, Boyfriend, Single etc
How Many Years Have You Suffered Pain From Endometriosis?
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Please Tick Current Symptoms
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Irregular Bleeding
Bleeding 3-5 Days
Bleeding 6-9 Days
Bleeding 10-13 Days
Bleeding 14 Days +
Flooding
Spotting
Blood Clots
Ovulation Pain (Day 14 +)
Unexplained Weight Gain
Unable to Keep Weight On
Hair Thinning
Migraines
Breast Pain
Nipple Pain
Lower Back Pain
Kidney Pain
Ovary Pain
Bladder Pressure
Frequent Urination
Bladder Infections
Pain on Urination
Pain with Bowel Movements
Constipation
Diarrhoea
Night Sweats
Vaginal Dryness
Painful Intercourse
Hot Flashes
Memory Problems
Poor Sleep
Chronic Fatigue
Weepiness
Depression
Lethargy
Chronic Fatigue
Bloating
Distended Stomach
Painful Sex
Candida
Restless Itchy Legs
Chemical Sensitivities
OvarianCysts
Chocolate Cysts
Dragging Sensation Down Legs
Other
Please List ANY/ALL Other Negative Symptoms Occurring in Your Body that are Not Mentioned Above
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This can be anything from indigestions to dry skin, eczema to ingrown toe nails...
What Are Your Average Daily Pain Scores?
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1-4 Mild Pain
5-7 Moderate Pain
8-10 High Pain
Only at Menstruation
Only at Ovulation
Please Describe in More Details About Your Pain Scores (If Required)
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Dragging, Stabbing, Burning, Piercing, etc
Personal History
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Diabetes
Low Blood Pressure
High Blood Pressure
Low Blood Sugar
Multiple Chemical Sensitivites
Frequent Colds/Flu
Allergies
Yeast Infections
Thryoid Problems
Hyper-thryroidism
Hypo-thyroidism
Ulcers
Eczema
Sensitive to Light & Sound
Kidney Problems
Chronic Fatigue
PTSD
Childhood Trauma
Anxiety
Insomnia
Please Detail Any Other Symptoms Not Mentioned Above
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Please List Any Other Medical Conditions You Suffer From
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What Do You Use?
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Cannibis Patch
Cigarettes
Cannibis
Electronic Cigarette
Cocaine
Rolled Tobacco
None of the above
Alcohol
What Do You Use?
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Antacids
Aspirin
Tramadol
Ibruprofen
Paracetamol
Morphine Patches
Laxatives
Suppositories
Lupron
None of the above
List Any Other Medications Or Items Not Listed Above
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Number of Operations?
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None
1
2
3
4
5+
Number (if over 5)
Please Detail The Operations & Surgeries You Have Had
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How Many Hours Sleep Do You Have A Night?
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1-3 Hours
4-6 Hours
7-8 Hours
Struggle with full night's sleep
Other
What Do Drink?
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Beer
Wine
Spirits
Lager
Cider
Do Not DrinkAlcohol
What Do You Eat?
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Refined Sugars
Fizzy Drinks/Coka Cola/Sprite etc
Margarine
Chewing Gum
Commercial Salt
Artificial Sweeteners
Alcohol
Tap Water
Energy Drinks
Coffee
Tea
Microwaveable Meals
Appetite Suppressants
Decaffeinated Coffee
Fast Foods
White Bread
Biscuits/Cakes
Cows Milk
What Foods Do You Crave?
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Please do not feel ashamed or guilty, this is just information gathering to increase awareness at this stage
How Are Your Nails (Weak/Brittle/White Spots)
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What Is Your Main Complaint(s) In Your Body At The Moment?
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What Areas of Your Life Are Stressful?
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WHO In Your Life Is Stressful?
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(*If there are more than one please list them)
WHY Is This Person(s) Stressful?
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What 'Unpleasant' Emotions Are Showing Up Now?
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Anxiety
Fear
Depression
Overwhelm
Sadness
Anger
Other
What 'Pleasant' Emotions Are Showing Up Now?
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Excitement
Hope
Optimism
Trusting in Right Place/Right Time
Trusting Safe EndoBoss Team
Blind Faith
Other
What Emotions Do You Wish To Feel MORE Of In 12 Months Time?
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Peace
Joy
Acceptance
Serenity
Playfulness
Please Name The 'Parts' You Are Aware Of At The Moment?
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Inner Child
Adolescence
HUGGS (HigherPower, Universe, God, Goddess, Source
Widsom
Parent
Neglected Child
Playful Child
Magical Child
Pusher
Perfectionist
Critic
Good Girl
EndoBoss In Training
People Pleaser
Other
What Emotions Are Regular & Evident As You Begin This Empowering Journey?
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Explore this in your journal. Be honest with yourself as we will be referring back to this Opening Questionnaire when you do your Podcast interview with Wendy in 12 months time sharing your Success Story.
Please List All Supplements & Vitamins Brands & Quantity That You Are Currently Taking Along with Dosage
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You will be asked to submit photographs and full details of ALL of your current supplements into the Facebook Group for the Team to ensure there are no 'nasties' hiding in the ingredients
You Would Be Required To Purchase Recommended Supplements As Part Of The Program. Please Confirm You Would Be Prepared To Do So.
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Yes
No
What Top 5 Elements Would You Hope To Achieve Out of The Program In 12 Months Time
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How Self Motivated Are You? Please Provide An Example.
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Please provide an example of something you have committed to in the past and how you followed through?
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Have You Read Wendy's Book "How I Ended My Endometriosis Naturally Without Painkillers, Drugs or Surgery"?
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What New Pieces Of Information Did You Discover From Her Book?
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What Steps Have You Already Taken To Try & Heal Your Endometriosis Naturally?
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REMEMBER - This is NOT A Quick Fix Program & Requires Full 100% Commitment and Dedication which Involves Lifestyle Changes over a MINIMUM 12 Months* - Please Explain What Makes You Sure You Would Continue for the Full Term of Program & Not Give Up?
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Have You Completed Any Other Programs or Events With Wendy?
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21 Day EndoBoss® Challenge
Embracing Emotions, Empathy & Energy
12 Months EndoBoss® Client Academy Program (Supported)
12 Months Become A Certified Emotionologist Coach Program
Advanced PLUS Purpose, Personal Power & People Protection Program
12 Weeks Certified EndoBoss Coach
Unleash Your Inner Picasso Program
Podschool 'Broadcast Your Podcast' Program
Entrepreneur Business Boost Program
Ultimate Emotional Health Summit MasterClass 2020
Ultimate Emotional Health Summit MasterClass 2021
Private 1-1 Coaching with Wendy
Embracing Emotions Retreat
UnBlock Emotional Blocks Retreat
Not completed any others yet
What is your 'WHY'? Tell Us WHY you REALLY want to heal your Endometriosis Naturally/What Are Your Dreams?
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What are your dreams and/or goals for your life when you are pain-free and symptom-free?
It Is 12 Months From Now. What Would Have Had To Have Happened Personally & Professionally For You To Feel A REAL Success?
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Dream big, have faith in your AMAZING body and the Laidlaw Protocols
You Meet With Up Wendy Personally in 12 Months Time To Be Presented With Your EndoBoss® Medal. (And To Have a Power Shake or Green Juice!). You Have Achieved ALL Of The Success You Sought In Many Areas of Your Life. Take Time To Think & Visualise What This Conversation Would Be Like. What Would You Be Sharing With Wendy? (Be Brave & Have Faith & Fun With This & Write Visualise How You Will Feel)
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Where Did You Hear About Wendy?
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Google, Bing, Radio Station, TV Interview, Health Magazine, Authority Magazine, BBC Radio, Facebook HEN Page, Facebook Advert, Read Book, Word of Mouth, Twitter, Linkedin, etc
What Was The Main Deciding Factor That Made You Invest In Yourself At This Time?
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The EndoBoss Support Team, listening to Wendy's Podcast, reading Wendy's book, confidence building from previous programs, gave me hope, needed support, tired of being on my own, etc
What T-Shirt Size Are You?
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Extra Small
Small
Medium
Large
Note:
*PLEASE NOTE - This information is gathered for information purposes only and is not intended as medical advice, diagnosis or treatment. This information is STRICTLY confidential and is used to monitor the progress and improvement of symptoms throughout the program. It is absolutely NEVER shared with anyone else. If you have any questions at any stage please do not hesitate to contact Support@HealEndometriosisNaturallyZohoDesk.com.
Please Add YES in this Box to confirm you understand the above note.
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