Prac email
Email prac
Name
*
First
Last
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
Acne
Alcoholism
Allergies
Anemia
Anger
Anxiety
Arthritis, Osteo
Arthritis, Rheumatoid
Asthma
Attention Deficit
Autism
Bipolar Disorder
Bladder Infections
Bloating
Bronchitis
Bursitis
Cataracts
Cirrhosis
Cold in Winter/Dry Skin
Confusion
Constipation
Cough
Depression
Dental Amalgams
Delayed Development
Depression
Diabetes
Diarrhea
Dizziness
Drug Addiction
Easy Bruising
Emphysema
Eczema
Eye diseases
Fear
Fissures
Fractures
Frequent Urination
Gall Stones
Gout
Glaucoma
Heart Attack
Heartburn
Heart Palpitations
Hemorrhoids
High Cholesterol
High Triglycerides
Hives
Hypoglycemia
Hypothyroidism
Intestinal Gas
Irritable before meals
Irritability
Kidney Infections
Kidney Stones
Learning Disability
Low or High Blood Pressure
Low Body Temperature
Meniere’s Disease
Mental Retardation
Migraine Headaches
Mind Races
Multiple Sclerosis
Muscle Cramps
Muscle Pain
Muscle Weakness
No hunger
Obsessive/Compulsive
Other Food Cravings
Painful Urination
Panic Attacks
Parkinson’s Disease
Poor Circulation
Poor Memory
Psoriasis
Rapid Heart Rate
Seizures
Schizophrenia
Scleroderma
Sinus Congestion
Sinus Headaches
Skipped Heart Rate
Smoking
Stomach Pain
Sugar Reactions
Sweet Cravings
Tend to Gain Weight
Tend to Lose Weight
Tension Headaches
Trouble Sleeping
Trouble Urinating
Tumors/Cancer
Ulcer
Water Retention
Visual Snow
Women
Abnormal Pap Smear
Abuse
Breast Tumors
Cramps
Currently pregnant
Fibrocystic Breasts
Fibroid Tumors
Heavy periods
Hot Flashes
Light/Irregular Periods
Menopause
No Menstruation
Ovarian Cysts
Premenstrual Syndrome
Rape
Water Retention
Yeast Infections
Men
Impotence
Infertility
Prostate Problems
Vegetarian / Vegan
Vegetarian
Vegan
IF YOU CURRENTLY HAVE NO SYMPTOMS CLICK YES
Yes
Other Symptoms or comments
For more accurate supplement recommendations please select all that apply here
Allergies/colds/sinus congestion/gum disease
Cancer history
Constipation
Diabetes
Diarrhea
Currently menstruating
Fungal infections/candida
Graves disease
Herpes
High blood pressure
High cholesterol and/or triglycerides
Hyperthyroidism
Hypoglycemia or sweet cravings
Insomnia/trouble sleeping
Osteopenia/osteoporosis