Please enable JavaScript in your browser to complete this form.Today's Date *Name *Age *Sex *MaleFemaleAddress *City *State *Zip Code *CountryPlease answer the questions below to help us set up your new program:On a scale of 0-5, how closely have you been following your program (0=not at all 5=perfectly)Diet Selected Value: 0 Rest Selected Value: 0 Coffee Enemas Selected Value: 0 Supplements Selected Value: 0 Sauna/heat-lamp Selected Value: 0 Water Selected Value: 0 What is your current diet? Please don’t fudge on this – I know it can be embarrassingBreakfast *Breakfast Beverages *Lunch *Lunch Beverages *Supper *Supper Beverages *Evening Snacks *Evening Snacks Beverages *Describe changes you have you 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 other concerns you would like us to address when updating your healing program *SYMPTOMSSYMPTOMSJoint_PainJoint_StiffnessArthritis,_OsteoArthritis,_RheumatoidMuscle_PainMuscle_WeaknessMuscle_CrampsBursitisFracturesOsteoporosisGoutSweet_CravingsSugar_ReactionsIrritable_before_mealsCant_Skip_MealsHypoglycemiaCrave_StarchesFat_CravingsOther_Food_CravingsFood_AllergiesExcessive_hungerNo_hungerDiabetesRapid_Heart_RateSkipped_Heart_BeatsHeart_PalpitationsHeart_AttackPoor_CirculationDizzinessLow_Blood_PressureHigh_Blood_PressureAnginaArteriosclerosisHigh_CholesterolHigh_TriglyceridesCoughBronchitisAsthmaPost-nasal_DripSinus_CongestionAllergiesEmphysemaFatigueHypothyroidismLow_Body_TemperatureCold_in_Winter/Dry_SkinTend_to_Gain_WeightHyperthyroidismAcneEczemaFungal_Infections/CandidaPsoriasisHivesHair_LossSlow_Wound_HealingCataractsGlaucomaMenieres_DiseaseTooth_DecayExcessive_Tooth_PlaqueGum_DiseaseInfections/VirusesMultiple_SclerosisParkinsons_DiseaseSclerodermaAngerAnxietyBipolar_DisorderBrain_FogConfusionDepressionIrritabilityMind_RacesMood_SwingsObsessive/CompulsivePanic_AttacksPoor_MemorySchizophreniaTrouble_SleepingAutismAttention_DeficitHyperkinesisDyslexiaSeizuresLearning_DisabilityMental_RetardationDelayed_DevelopmentBladder_InfectionsKidney_InfectionsTrouble_UrinatingFrequent_UrinationPainful_UrinationKidney_StonesWater_RetentionKidney_StonesWater_RetentionSinus_HeadachesTension_HeadachesMigraine_HeadachesNeuritisEye_diseasesConstipationDiarrheaIntestinal_GasBloatingHeartburnUlcerStomach_PainColitisGall_StonesFissuresHemorrhoidsCirrhosisDiverticulitisTend_to_Gain_WeightTend_to_Lose_WeightAnemiaEasy_BruisingDrug_AddictionAlcoholismSmokingTumorCancerMENS SYMPTOMSMENS SYMPTOMSProstate_ProblemsImpotenceInfertilityWOMENS SYMPTOMSWOMENS SYMPTOMSPremenstrual_SyndromeWater_RetentionCrampsNo_MenstruationHeavy_periodsLight/Irregular_PeriodsOvarian_CystsFibroid_TumorsAbnormal_Pap_SmearMenopauseFibrocystic_BreastsBreast_TumorsYeast_InfectionsHot_FlashesWhich symptoms concern you the most. *Other Symptoms. *How do you want your results delivered *Email Audio MP3Phone ConsultationPlease provide email address and phone number Submit
