Please click here to read our Release Form.

Please provide the following contact information:
First Name:
Last Name:
Street Address:
Zip Code:  
Home Phone:
Date of Birth:
Who referred You:
Number of organs removed, including teeth:
How manyprescription drugs do you use:  
How many cigarettes/cigars do you smoke per day:
Number of steroid type drugs used in the last year:  
Number of street drugs used in the past:
How many different allergies:

What is bothering you emotionally or mentally: (depression, anger, anxiety)


On a scale of 1-10, how responsible are you for your health:

How much fat is in your diet (2-low, 3-medium, 4-high):
Your negativity level (from 1-10):
What is your personal stress level (from 1-10):  
Do you take vitamins daily:
How many sugar type products do you have a day:  
How many exercise sessions of 20 mins or more a week:  
On average, number of alcoholic drinks per day:  
Number of cups of coffee or tea with caffeine a day:  
Number of extreme toxic exposures per year (radiation, insecticides, chemicals):  
What major injuries have you had in the past (accidents, falls, surgery):  
Number of major infections:  
How many glasses of water do you drink a day:  
How many pounds overweight, if any:  
How do you feel on a scale of 1-10 (lowest to highest):  




DISCLAIMER: None of the above is meant to diagnose, treat, prescribe or claim to cure any disease. Clients are advised that they should consult their own medical practitioners and medical professionals for the diagnoses, care, treatment or cure of any health condition.