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Introduction
Diet
Detox Introduction
Coffee enemas
Saunas
Supplements
Healing reactions

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BOOK A DEMO CALL
PRACTITIONERS
Individuals
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Contact
Subscriptions
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- Subscription Account
Login
Dashboard

BOOK A DEMO CALL
PRACTITIONERS
Individuals
Generate a report
Get a HTMA
Contact
Subscriptions
- Get a subscription
- Subscription Account
Login
Dashboard

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Prac email
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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

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