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Email prac
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?
Please list any medications you are currently taking
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
- Brain Fog
- Fatigue
- Mood Swings
- Post-nasal Drip
On a scale of 1-10 below please type in the severity of your symptoms.
Acne - severity
Please enter a number from 0 to 10.
Alcoholism - severity
Please enter a number from 0 to 10.
Allergies - severity
Please enter a number from 0 to 10.
Anemia - severity
Please enter a number from 0 to 10.
Anger - severity
Please enter a number from 0 to 10.
Anxiety - severity
Please enter a number from 0 to 10.
Arthritis, Osteo - severity
Please enter a number from 0 to 10.
Arthritis, Rheumatoid - severity
Please enter a number from 0 to 10.
Asthma - severity
Please enter a number from 0 to 10.
Attention Deficit - severity
Please enter a number from 0 to 10.
Autism - severity
Please enter a number from 0 to 10.
Bipolar Disorder - severity
Please enter a number from 0 to 10.
Bladder Infections - severity
Please enter a number from 0 to 10.
Bloating - severity
Please enter a number from 0 to 10.
Bronchitis - severity
Please enter a number from 0 to 10.
Bursitis - severity
Please enter a number from 0 to 10.
Cataracts - severity
Please enter a number from 0 to 10.
Cirrhosis - severity
Please enter a number from 0 to 10.
Cold in Winter/Dry Skin - severity
Please enter a number from 0 to 10.
Confusion - severity
Please enter a number from 0 to 10.
Constipation - severity
Please enter a number from 0 to 10.
Cough - severity
Please enter a number from 0 to 10.
Depression - severity
Please enter a number from 0 to 10.
Dental Amalgams - severity
Please enter a number from 0 to 10.
Delayed Development - severity
Please enter a number from 0 to 10.
Depression - severity
Please enter a number from 0 to 10.
Diabetes - severity
Please enter a number from 0 to 10.
Diarrhea - severity
Please enter a number from 0 to 10.
Dizziness - severity
Please enter a number from 0 to 10.
Drug Addiction - severity
Please enter a number from 0 to 10.
Easy Bruising - severity
Please enter a number from 0 to 10.
Emphysema - severity
Please enter a number from 0 to 10.
Eczema - severity
Please enter a number from 0 to 10.
Eye diseases - severity
Please enter a number from 0 to 10.
Fear - severity
Please enter a number from 0 to 10.
Fissures - severity
Please enter a number from 0 to 10.
Fractures - severity
Please enter a number from 0 to 10.
Frequent Urination - severity
Please enter a number from 0 to 10.
Gall Stones - severity
Please enter a number from 0 to 10.
Gout - severity
Please enter a number from 0 to 10.
Glaucoma - severity
Please enter a number from 0 to 10.
Heart Attack - severity
Please enter a number from 0 to 10.
Heartburn - severity
Please enter a number from 0 to 10.
Heart Palpitations - severity
Please enter a number from 0 to 10.
Hemorrhoids - severity
Please enter a number from 0 to 10.
High Cholesterol - severity
Please enter a number from 0 to 10.
High Triglycerides - severity
Please enter a number from 0 to 10.
Hives - severity
Please enter a number from 0 to 10.
Hypoglycemia - severity
Please enter a number from 0 to 10.
Hypothyroidism - severity
Please enter a number from 0 to 10.
Intestinal Gas - severity
Please enter a number from 0 to 10.
Irritable before meals - severity
Please enter a number from 0 to 10.
Irritability - severity
Please enter a number from 0 to 10.
Kidney Infections - severity
Please enter a number from 0 to 10.
Kidney Stones - severity
Please enter a number from 0 to 10.
Learning Disability - severity
Please enter a number from 0 to 10.
Low or High Blood Pressure - severity
Please enter a number from 0 to 10.
Low Body Temperature - severity
Please enter a number from 0 to 10.
Meniere’s Disease - severity
Please enter a number from 0 to 10.
Mental Retardation - severity
Please enter a number from 0 to 10.
Migraine Headaches - severity
Please enter a number from 0 to 10.
Mind Races - severity
Please enter a number from 0 to 10.
Multiple Sclerosis - severity
Please enter a number from 0 to 10.
Muscle Cramps - severity
Please enter a number from 0 to 10.
Muscle Pain - severity
Please enter a number from 0 to 10.
Muscle Weakness - severity
Please enter a number from 0 to 10.
No hunger - severity
Please enter a number from 0 to 10.
Obsessive/Compulsive - severity
Please enter a number from 0 to 10.
Other Food Cravings - severity
Please enter a number from 0 to 10.
Painful Urination - severity
Please enter a number from 0 to 10.
Panic Attacks - severity
Please enter a number from 0 to 10.
Parkinson’s Disease - severity
Please enter a number from 0 to 10.
Poor Circulation - severity
Please enter a number from 0 to 10.
Poor Memory - severity
Please enter a number from 0 to 10.
Psoriasis - severity
Please enter a number from 0 to 10.
Rapid Heart Rate - severity
Please enter a number from 0 to 10.
Seizures - severity
Please enter a number from 0 to 10.
Schizophrenia - severity
Please enter a number from 0 to 10.
Scleroderma - severity
Please enter a number from 0 to 10.
Sinus Congestion - severity
Please enter a number from 0 to 10.
Sinus Headaches - severity
Please enter a number from 0 to 10.
Skipped Heart Rate - severity
Please enter a number from 0 to 10.
Smoking - severity
Please enter a number from 0 to 10.
Stomach Pain - severity
Please enter a number from 0 to 10.
Sugar Reactions - severity
Please enter a number from 0 to 10.
Sweet Cravings - severity
Please enter a number from 0 to 10.
Tend to Gain Weight - severity
Please enter a number from 0 to 10.
Tend to Lose Weight - severity
Please enter a number from 0 to 10.
Tension Headaches - severity
Please enter a number from 0 to 10.
Trouble Sleeping - severity
Please enter a number from 0 to 10.
Trouble Urinating - severity
Please enter a number from 0 to 10.
Tumors/Cancer - severity
Please enter a number from 0 to 10.
Ulcer - severity
Please enter a number from 0 to 10.
Water Retention - severity
Please enter a number from 0 to 10.
Visual Snow - severity
Please enter a number from 0 to 10.
Brain Fog - severity
Please enter a number from 0 to 10.
Fatigue - severity
Please enter a number from 0 to 10.
Mood Swings - severity
Please enter a number from 0 to 10.
Post-nasal Drip - severity
Please enter a number from 0 to 10.
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
On a scale of 1-10 below please type in the severity of your symptoms.
Abnormal Pap Smear - severity
Please enter a number from 0 to 10.
Abuse - severity
Please enter a number from 0 to 10.
Breast Tumors - severity
Please enter a number from 0 to 10.
Cramps - severity
Please enter a number from 0 to 10.
Currently pregnant - severity
Please enter a number from 0 to 10.
Fibrocystic Breasts - severity
Please enter a number from 0 to 10.
Fibroid Tumors - severity
Please enter a number from 0 to 10.
Heavy periods - severity
Please enter a number from 0 to 10.
Hot Flashes - severity
Please enter a number from 0 to 10.
Light/Irregular Periods - severity
Please enter a number from 0 to 10.
Menopause - severity
Please enter a number from 0 to 10.
No Menstruation - severity
Please enter a number from 0 to 10.
Ovarian Cysts - severity
Please enter a number from 0 to 10.
Premenstrual Syndrome - severity
Please enter a number from 0 to 10.
Rape - severity
Please enter a number from 0 to 10.
Water Retention - severity
Please enter a number from 0 to 10.
Yeast Infections - severity
Please enter a number from 0 to 10.
Men
- Impotence
- Infertility
- Prostate Problems
On a scale of 1-10 below please type in the severity of your symptoms.
Impotence - severity
Please enter a number from 0 to 10.
Infertility - severity
Please enter a number from 0 to 10.
Prostate Problems - severity
Please enter a number from 0 to 10.
Vegetarian / Vegan
- Vegetarian
- Vegan
On a scale of 1-10 below please type in the severity of your symptoms.
Vegetarian - severity
Please enter a number from 0 to 10.
Vegan - severity
Please enter a number from 0 to 10.
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
Allergies/colds/sinus congestion/gum disease - severity
Please enter a number from 0 to 10.
Cancer history - severity
Please enter a number from 0 to 10.
Constipation - severity
Please enter a number from 0 to 10.
Diabetes - severity
Please enter a number from 0 to 10.
Diarrhea - severity
Please enter a number from 0 to 10.
Currently menstruating - severity
Please enter a number from 0 to 10.
Fungal infections/candida - severity
Please enter a number from 0 to 10.
Graves disease - severity
Please enter a number from 0 to 10.
Herpes - severity
Please enter a number from 0 to 10.
High blood pressure - severity
Please enter a number from 0 to 10.
High cholesterol and/or triglycerides - severity
Please enter a number from 0 to 10.
Hyperthyroidism - severity
Please enter a number from 0 to 10.
Hypoglycemia or sweet cravings - severity
Please enter a number from 0 to 10.
Insomnia/trouble sleeping - severity
Please enter a number from 0 to 10.
Osteopenia/osteoporosis - severity
Please enter a number from 0 to 10.

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