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Introduction
Diet
Detox Introduction
Coffee enemas
Saunas
Supplements
Healing reactions
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Prac email
Hidden
Email prac
Test number
How many tests have you done? For example, if this is your 4th HTMA please type 4
Full Name
*
Age
*
Date
City
*
Post Code
*
State / Province
*
Country
*
Home Phone
*
Business Phone
Email
*
On a scale of 0-5, how closely have you been following your program? 0=not at all, 5=perfectly
Diet
*
Please enter a number from
0
to
5
.
Supplements
*
Please enter a number from
0
to
5
.
Water
*
Please enter a number from
0
to
5
.
Lifestyle
*
Please enter a number from
0
to
5
.
Rest
*
Please enter a number from
0
to
5
.
Sauna or heat lamp.
*
Please enter a number from
0
to
5
.
Spinal Twist
*
Please enter a number from
0
to
5
.
Foot Rubs
*
Please enter a number from
0
to
5
.
Coffee Enemas
*
Please enter a number from
0
to
5
.
Meditation
*
Please enter a number from
0
to
5
.
Skin Brushing
*
Please enter a number from
0
to
5
.
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!
DIET: What are examples of typical breakfasts for you?
*
Beverages
*
What are typical lunches for you?
*
Beverages
*
What are typical dinners for you?
*
Beverages
*
Describe changes you have noticed in your symptoms over the past several months.
Do you have any questions about your supplements, diet program, sauna therapy or coffee enemas?
Do you have any questions about emotional aspects, meditation, or lifestyle challenges?
Are there any other concerns you would like us to address when updating your healing program?
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 Carvings
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
Tend to Gain Weight
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
Men
Prostate Problems
Impotence
Infertility
Vegetarian / Vegan
Vegetarian
Vegan
IF YOU CURRENTLY HAVE NO SYMPTOMS CLICK YES
Yes
Other Symptoms or comments
