San Franscisco Medical Research Foundation
Presents
The Human Ecology Program
A Comprehensive Health Maintenance and Rejuvenation Program

COMMITMENT

QUESTIONNAIRE

The purpose of this questionnaire is to measure your degree of commitment to your own self-healing and regeneration, and to this program as a means of facilitating your success.

Please check yes or no and explain.

1. Do you understand the philosophy, science and rationale for The Human Ecology Program? Yes / No

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2. Do you believe that by following the guidelines of this program real progress will be made in realizing your goals? Yes / No

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3. Are you ready to take the necessary steps in assuming responsibility for your life? Yes / No

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4. Have you instituted a consistent exercise program for yourself? Yes No

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5. Have you made a conscious commitment toward a semi-vegetarian diet as recommended in this program? Yes / No

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6. Do you intend to cleanse and rejuvenate your body by fasting in the near future? Yes / No

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7. Are you taking positive action in creating a health­ier environment at work and at home? Yes / No

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8. Are you conscientiously using the music and video tapes we offer to inspire and heal yourself? Yes / No

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9. Do you consistently find time for your spiritual practices of meditation, prayer and communion? Yes / No

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10. Are you consciously applying the science of breath so as to promote deeper levels of awareness, relaxation and a sense of peace? Yes / No

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11. Have you gone to a chiropractic and/or massage therapist? Yes / No

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12. Are you learning to love and trust yourself? Yes / No

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