Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
FAX
E-mail
URL

           Please identify and describe yourself:

Date of Birth
Sex	Male Female
Height
Weight
Hair Color	Blonde Brown Black Red Gray White
Eye Color	Blue Brown Black Green Gray Violet

           What brought you to do the Clark Kidney Cleanse? (IE:  Did your read about it in one of Dr. Clark's books?  

Are You Doing This Kidney Cleanse in Conjunction With Any Other Clark Program?

Liver Flush
Parasite Program
Bowel Program
HIV/AIDS Program
21 Day Cancer Program
Plate Zapping

 

Choose one of the following options:  I'm doing the Kidney Cleanse because I'm dealing with issues of:

General Health
Cancer
HIV/AIDS
Multiple Sclerosis
Other 

What specific physical results did you get from the Clark Kidney Cleanse? (IE:  Did you find stones? 

 

How was your general health BEFORE you began this Clark Program?

bad poor average fair good

 

How is your general health AFTER completing this Clark Program?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to participate in vigorous physical activity (running, strenuous sports)?

bad poor   average fair good

 

AFTER this program, at what level could you describe your ability to participate in vigorous physical activity (running, strenuous sports)?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to participate in MODERATE activity (vacuuming, playing golf)?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to participate in MODERATE activity (vacuuming, playing golf)?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to participate in COMMON activity (lifting, carrying groceries)?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to participate in COMMON activity (lifting, carrying groceries)?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to climb several flights of stairs?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to climb several flights of stairs?

bad poor average fair good

BEFORE this program, at what level could you describe your ability to climb ONE flight of stairs?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to climb ONE flight of stairs?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to bend, kneel, or stoop?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to bend, kneel, or stoop?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to walk more than a mile?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to walk more than a mile?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to walk several hundred yards?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to walk several hundred yards?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to walk one hundred yards?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to walk one hundred yards?

bad poor average fair good

 

BEFORE this program, at what level could you describe your ability to bathe, or dress yourself?

bad poor average fair good

 

AFTER this program, at what level could you describe your ability to bathe, or dress yourself?

bad poor average fair good

 

As a Result of Your Physical Health:  In the four weeks BEFORE you did this program, did you have to cut down on the amount of time you spent on work or activities?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: AFTER you did this program, did you have to cut down on the amount of time you spent on work or activities?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: In the four weeks BEFORE you did this program, did you accomplish less than you would like?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: AFTER you did this program, did you accomplish less than you would like?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: In the four weeks BEFORE you did this program, were you limited in the kind of  work you do, or other activities?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: AFTER you did this program, were you limited in the kind of work you do, or other activities?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: In the four weeks BEFORE you did this program, were you having difficulty performing work or other activities?

all of the time most of the time some times a little none

 

As a Result of Your Physical Health: AFTER you did this program, were you having difficulty performing work or other activities?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious): In the four weeks BEFORE you did this program, did you have to cut down on the amount of time you spent on work or activities?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious):  AFTER you did this program, did you have to cut down on the amount of time you spent on work or activities?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious):  In the four weeks BEFORE you did this program, did you accomplish less than you would like?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious):  AFTER you did this program, did you accomplish less than you would like?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious):  In the four weeks BEFORE you did this program, did you do work less carefully than usual?

all of the time most of the time some times a little none

 

As a Result of Your Emotional Health (such as feeling depressed or anxious):  AFTER you did this program, did you do work less carefully than usual?

all of the time most of the time some times a little none

 

In the four weeks BEFORE you did this program, has your PHYSICAL HEALTH or your EMOTIONAL PROBLEMS interfered with your normal social activities with family, friends, neighbors, or groups?

not at all slightly moderately quite a bit extremely

 

AFTER you did this program, has your PHYSICAL HEALTH or your EMOTIONAL PROBLEMS interfered with your normal social activities with family, friends, neighbors, or groups?

  not at all slightly moderately quite a bit extremely

 

In the four weeks BEFORE you did this program, how much bodily pain have you had?

none very mild mild moderate severe very severe

 

AFTER you did this program, how much bodily pain have you had?

  none very mild mild moderate severe very severe

 

In the four weeks BEFORE you did this program, how much did pain interfere with your normal work (inside and outside the home)?

not at all slightly moderately quite a bit extremely

 

AFTER you did this program, how much did pain interfere with your normal work (inside and outside the home)?

  not at all slightly moderately quite a bit extremely

 

How much of the time during the four weeks BEFORE you did this program, did you feel full of life?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel full of life?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, were you very nervous?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, were you very nervous?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you feel that nothing could cheer you up??

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel that nothing could cheer you up?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you feel calm and peaceful?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel calm and peaceful?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you have a lot of energy?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you have a lot of energy?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you feel downhearted and depressed?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel downhearted and depressed?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you feel worn out?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel worn out?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, have you been happy?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, have you been happy?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, did you feel tired?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, did you feel tired?

all of the time most of the time some of the time a little none of the time

 

How much of the time during the four weeks BEFORE you did this program, has your PHYSICAL HEALTH or your EMOTIONAL PROBLEMS interfered with your normal social activities with family, friends, neighbors, or groups?

all of the time most of the time some of the time a little none of the time

 

AFTER you did this program, has your PHYSICAL HEALTH or your EMOTIONAL PROBLEMS interfered with your normal social activities with family, friends, neighbors, or groups?

all of the time most of the time some of the time a little none of the time

 

True or False:  BEFORE I did this program,  I seemed to get sick a little easier than other people...

definitely true mostly true don't know mostly false definitely false

 

True or False:  AFTER I did this program, I seemed to get sick a little easier than other people...

  definitely true mostly true don't know mostly false definitely false

 

True or False:  BEFORE I did this program,  I was as healthy as anybody I know...

definitely true mostly true don't know mostly false definitely false

 

True or False:  AFTER I did this program, I was as healthy as anybody I know...

definitely true mostly true don't know mostly false definitely false

 

True or False:  BEFORE I did this program,  I expected my health to get worse...

definitely true mostly true don't know mostly false definitely false

 

True or False:  AFTER I did this program, I expected my health to get worse...

  definitely true mostly true don't know mostly false definitely false

 

True or False:  BEFORE I did this program,  I rated my health as excellent...

definitely true mostly true don't know mostly false definitely false

 

True or False:  AFTER I did this program, I rated my health as excellent...

  definitely true mostly true don't know mostly false definitely false