Gis and retest input – Hair Analysis App

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Prac email 2
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entry_id
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GRAPH
- ARL (Analytical Labs)
is prac
- Yes
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Full Name
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Lab Number
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Sex*
- Male
- Female
Is this a retest?*
- Yes
- No
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Age*
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Calcium
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Calcium-previous number
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Magnesium
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Magnesium-previous number
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Sodium
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Sodium-previous
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Potassium
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Potassium-previous number
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Iron
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Iron-previous
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Copper
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Copper-previous
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Manganese
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Manganese-previous
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Zinc
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Zinc-previous
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Chromium
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Chromium-previous
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Selenium
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Selenium previous
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Phosphorus
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Phosphorus-previous
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Sulphur
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Sulphur-Previous
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Lead
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Lead-previous
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Mercury
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Mercury-previous
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Cadmium
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Cadmium-previous
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Arsenic
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Arsenic-previous
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Aluminium
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Aluminium-previous
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Nickel
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Nickel-previous
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Cobalt
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Cobalt previous
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Molybdenum
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Molybdenum previous
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Lithium
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Lithium previous
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Assign this program to a previously saved client?
- Yes
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Email
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Client notes
Import Client General Information Sheet
Here you can import client data if you sent them a GIS form from our system, if you didn't you can still add this manually.
Import Client Retest Information Sheet
Here you can import client data if you sent them a retest form from our system, if you didn't you can still add this manually.
Hide required
- Yes
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Prac email
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Name*
First Last
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D.O.B*
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Age*
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Sex M/F*
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Date
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City*
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Address*
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County / State / Province*
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Post/Zip Code*
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Country*
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Phone*
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Email*
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Height*
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Weight*
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Occupation*
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How were you referred?*
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What are your main health concerns or conditions?*
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Please list any medications or food supplements you are currently taking:
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Please list any recent medical test results you have, such as blood tests:
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Any past surgeries and dates:
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Please list illness in your family such as heart disease, cancer, TB, diabetes, arthritis etc.
DIET

Please fill out the section below concisely and write exactly what foods you are eating. Please do not skip this and just write 'slow diet', 'nb diet' or 'veggies and protein'. It is important for us to know what you are eating so we can properly help. Thankyou!
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DIET: What are examples of typical breakfasts for you?*
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Beverages*
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Mid-morning Snacks:
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What are typical lunches for you?*
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Beverages*
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Mid-afternoon Snacks:
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What are typical dinners for you?*
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Beverages*
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Evening Snacks:
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How often and what exercise do you do?
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About how many hours of sleep do you get per day?*
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Alcohol use: Type / Ounces / How Often
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Tobacco: Type / How Often
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Recreational Drug use: Type / How Often
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I understand that Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease*
- Yes
- No
Symptoms List
- Joint Pain
- Joint Stiffness
- Arthritis, Osteo
- Arthritis, Rheumatoid
- Muscle Pain
- Muscle Weakness
- Muscle Cramps
- Bursitis
- Fractures
- Osteoporosis
- Gout
- Sweet Cravings
- Sugar Reactions
- Irritable before meals
- Can’t Skip Meals
- Hypoglycemia
- Crave Starches
- Fat Cravings
- Other Food Cravings
- Food Allergies
- Excessive hunger
- No hunger
- Diabetes
- Rapid Heart Rate
- Skipped Heart Rate
- Heart Palpitations
- Heart Attack
- Poor Circulation
- Dizziness
- Low or High Blood Pressure
- Angina
- High Cholesterol
- High Triglycerides
- Cough
- Bronchitis
- Asthma
- Post-nasal Drip
- Sinus Congestion
- Allergies
- Emphysema
- Fatigue
- Hypothyroidism
- Low Body Temperature
- Cold in Winter/Dry Skin
- Hyperthyroidism
- Acne
- Eczema
- Fungal Infections/Candida
- Psoriasis
- Hives
- Hair Loss
- Slow Wound Healing
- Cataracts
- Glaucoma
- Meniere’s Disease
- Tooth Decay
- Excessive Plaque on Teeth
- Gum Disease
- Infections/Viruses
- Tumors/Cancer
- Multiple Sclerosis
- Parkinson’s Disease
- Scleroderma
- Fear
- Anger
- Anxiety
- Bipolar Disorder
- Brain Fog
- Confusion
- Depression
- Irritability
- Mind Races
- Mood Swings
- Obsessive/Compulsive
- Panic Attacks
- Poor Memory
- Schizophrenia
- Trouble Sleeping
- Suicidal thoughts
- Autism
- Attention Deficit
- Hyperkinesis
- Dyslexia
- Seizures
- Learning Disability
- Mental Retardation
- Delayed Development
- Bladder Infections
- Kidney Infections
- Trouble Urinating
- Frequent Urination
- Painful Urination
- Kidney Stones
- Water Retention
- Sinus Headaches
- Tension Headaches
- Migraine Headaches
- Neuritis
- Eye diseases
- Constipation
- Diarrhea
- Intestinal Gas
- Bloating
- Heartburn
- Ulcer
- Stomach Pain
- Colitis
- Gall Stones
- Fissures
- Hemorrhoids
- Cirrhosis
- Diverticulitis
- Tend to Gain Weight
- Tend to Lose Weight
- Anemia
- Easy Bruising
- Dental Amalgams
- Drug Addiction
- Alcoholism
- Smoking
- Visual Snow
Symptoms List retest
- Joint Pain
- Joint Stiffness
- Arthritis, Osteo
- Arthritis, Rheumatoid
- Muscle Pain
- Muscle Weakness
- Muscle Cramps
- Bursitis
- Fractures
- Osteoporosis
- Gout
- Sweet Cravings
- Sugar Reactions
- Irritable before meals
- Can’t Skip Meals
- Hypoglycemia
- Crave Starches
- Fat Cravings
- Other Food Cravings
- Food Allergies
- Excessive hunger
- No hunger
- Diabetes
- Rapid Heart Rate
- Skipped Heart Rate
- Heart Palpitations
- Heart Attack
- Poor Circulation
- Dizziness
- Low or High Blood Pressure
- Angina
- High Cholesterol
- High Triglycerides
- Cough
- Bronchitis
- Asthma
- Post-nasal Drip
- Sinus Congestion
- Allergies
- Emphysema
- Fatigue
- Hypothyroidism
- Low Body Temperature
- Cold in Winter/Dry Skin
- Hyperthyroidism
- Acne
- Eczema
- Fungal Infections/Candida
- Psoriasis
- Hives
- Hair Loss
- Slow Wound Healing
- Cataracts
- Glaucoma
- Meniere’s Disease
- Tooth Decay
- Excessive Plaque on Teeth
- Gum Disease
- Infections/Viruses
- Tumors/Cancer
- Multiple Sclerosis
- Parkinson’s Disease
- Scleroderma
- Fear
- Anger
- Anxiety
- Bipolar Disorder
- Brain Fog
- Confusion
- Depression
- Irritability
- Mind Races
- Mood Swings
- Obsessive/Compulsive
- Panic Attacks
- Poor Memory
- Schizophrenia
- Trouble Sleeping
- Suicidal thoughts
- Autism
- Attention Deficit
- Hyperkinesis
- Dyslexia
- Seizures
- Learning Disability
- Mental Retardation
- Delayed Development
- Bladder Infections
- Kidney Infections
- Trouble Urinating
- Frequent Urination
- Painful Urination
- Kidney Stones
- Water Retention
- Sinus Headaches
- Tension Headaches
- Migraine Headaches
- Neuritis
- Eye diseases
- Constipation
- Diarrhea
- Intestinal Gas
- Bloating
- Heartburn
- Ulcer
- Stomach Pain
- Colitis
- Gall Stones
- Fissures
- Hemorrhoids
- Cirrhosis
- Diverticulitis
- Tend to Gain Weight
- Tend to Lose Weight
- Anemia
- Easy Bruising
- Dental Amalgams
- Drug Addiction
- Alcoholism
- Smoking
- Visual Snow
Women
- Premenstrual Syndrome
- Water Retention
- Cramps
- No Menstruation
- Heavy periods
- Light/Irregular Periods
- Ovarian Cysts
- Fibroid Tumors
- Abnormal Pap Smear
- Menopause
- Fibrocystic Breasts
- Breast Tumors
- Yeast Infections
- Hot Flashes
- Currently pregnant
- Abuse
- Rape
Women retest
- Premenstrual Syndrome
- Water Retention
- Cramps
- No Menstruation
- Heavy periods
- Light/Irregular Periods
- Ovarian Cysts
- Fibroid Tumors
- Abnormal Pap Smear
- Menopause
- Fibrocystic Breasts
- Breast Tumors
- Yeast Infections
- Hot Flashes
- Currently pregnant
- Abuse
- Rape
Men
- Prostate Problems
- Impotence
- Infertility
Men retest
- Prostate Problems
- Impotence
- Infertility
Vegetarian / Vegan
- Vegetarian
- Vegan
Vegetarian / Vegan retest
- Vegetarian
- Vegan
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IF YOU CURRENTLY HAVE NO SYMPTOMS CLICK YES
- Yes
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Other Symptoms or comments

DIET