Retest Client Questionnaire

New Client Input Form

Hi. I am excited to be working with you on your Mineral-Nutritional Balancing Journey! To get started, I need you to fill out all the information in this form. The information is kept private. This is a multi-page form. Please fill out all the information in this form. Thanks!

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Name *

First

Last

Email *

Email

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Date (MM/DD/YYYY) *

Age *

Phone Number *

If you are out of the US, please enter your country code.

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Height *

Weight *

Personalized Active Care Plan (PACP)

On a scale of 0-5, how closely have you been following your Personalized Active Care Plan?
 0 = not at all, 5 = doing well

Coffee Enema *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Diet *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Dry Skin Brushing *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Meditation *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Sauna/Sauna Light *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Supplements *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

Sleep *

• 0
• 1
• 2
• 3
• 4
• 5
• N/A

If you have any comments on how you have been following your PACP please let me know.

How Have You Been Doing?

Describe changes you’ve noticed in your symptoms or condition since you began your Personalized Active Care Plan. *

Do you have questions about your supplements and detoxification procedures? *

Is anything interfering with your ability to follow the program? *

Is there anything else you want me to know as I update your Personalized Active Care Plan? *

Any files to upload? Recent lab work, etc..

Click or drag a file to this area to upload.

Diet

What are examples of typical breakfasts for you (including beverages)? *

Proteins, Vegetables (if any), Grains (if any) and Beverages

Mid-morning snacks?

Fruit? Popcorn? Chips? Nothing?

What are examples of typical lunches for you (including beverages)? *

Proteins, Vegetables (if any), Grains (if any) and Beverages

Mid-afternoon snacks?

Fruit? Popcorn? Chips? Nothing?

What are examples of typical dinners for you (including beverages)? *

Proteins, Vegetables (if any), Grains (if any) and Beverages

Evening snacks?

Fruit? Popcorn? Chips? Nothing?

Health Issues & Life Experiences Questionnaire

Conditions/Symptoms (select all that apply) *

• Acne
• Addiction-alcohol
• Addiction-other substances
• Addiction-other
• Allergies-other than food
• Anemia
• Anger
• Angina
• Anxiety
• Arteriosclerosis
• Arthritis -osteo
• Arthritis -rheumatoid
• Asthma
• ADD/ADHD
• Autism
• Bipolar disorder
• Bloating
• Blood pressure-low
• Blood pressure-High
• Body temperature-low
• Brain fog
• Bronchitis
• Bruising-easy
• Bursitis
• Cholesterol-high
• Circulation-poor
• Cirrhosis
• Cold-feeling of
• Colitis
• Confusion
• Constipation
• Cough
• Depression
• Dermatitis
• Development-delayed
• Diabetes
• Diarrhea
• Diverticulitis
• Dizziness
• Dry Skin
• Dyslexia
• Eczema
• Emphysema
• Eyes-cataracts
• Eyes-glaucoma
• Eyes-macular degeneration
• Fatigue
• Fear
• Fissures
• Food-allergies
• Food cravings-fats
• Food cravings-starches
• Food cravings-sweets
• Food-cravings-other
• Food-can't skip meals
• Fractures
• Gallstones
• Gout
• Hair loss
• Headaches-migraine
• Headaches-sinus
• Headaches-tension
• Heart attack
• Heart-atrial fibrillation
• Heart-palpitations
• Heart rate-rapid
• Heartburn
• Hemorrhoids
• Hives
• Hunger-excessive
• Hunger-little to none
• Hyperkinesis
• Hyperglycemia
• Hypothyroidism
• Infection-bacterial
• Infection-fungal (e.g. Candidiadis)
• Infection-urinary tract
• Infection-viral
• Infertility
• Intestinal gas
• Irritability
• Irritability-before meals
• Joint pain
• Joint stiffness
• Kidney infection
• Kidney Stone(s)
• Learning disability
• Memory-poor
• Meniere's disease
• Mind racing
• Mood swings
• Multiple sclerosis
• Muscle-cramps
• Muscle-pain
• Muscle-weakness
• Neuritis
• Obsessive/compulsive
• Osteoporosis
• Panic attacks
• Parkinson's disease
• Postnasal drip
• Psoriasis
• Schizophrenia
• Scleroderma
• Seizures
• Sinus-congestion
• Sleep-insomnia
• Sleep-disturbance
• Smoking
• Stomach pain
• Sugar reactions
• Suicidal thoughts
• Teeth-decay
• Teeth-dental amalgams
• Teeth-excessive plaque
• Teeth-gum disease
• Triglycerides
• Tumour(s) / cancer
• Ulcer
• Urination-frequent
• Urination-painful
• Vertigo
• Water retention
• Weight-tend to gain
• Weight-tend to lose
• Wound healing-slow
• Yeast infection

Male *

• Not applicable
• Impotence
• Prostate problems

Select all that apply

Female *

• Not applicable
• Breasts-fibrocystic
• Breasts-tumors
• Fibroid tumors
• Hot flashes
• Menopause
• Menstruation-none
• Menstruation-heavy
• Menstruation-Irregular
• Menstruation-light
• Menstruation-cramps
• Ovarian cysts
• Pap smear-abnormal
• Pregnant-currently
• Premenstrual syndrome
• Yeast infection

Select all that apply

Trauma *

• Not applicable
• Abuse-emotional
• Abuse-physical
• Abuse-sexual

Comments

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Click or drag a file to this area to upload.

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