Retest Mineral Analysis Form

This retest includes your hair analysis, your consultation explaining your new mineral analysis and nutritional balancing program, and brief follow up phone calls or emails.

Disclaimer: Nutritional Balancing is a means to reduce stress and balance your minerals. Nutritional Balancing does not intend to diagnose, treat or prescribe medications for any condition or disease.

Name

Email Address

Postal Code

Country

Home Phone

Business Phone

How closely have you been following your program for your DIET? How closely have you been following your program for your DIET? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your SUPPLEMENTS? How closely have you been following your program for your SUPPLEMENTS? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your WATER? How closely have you been following your program for your WATER? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your LIFESTYLE? How closely have you been following your program for your LIFESTYLE? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your REST? How closely have you been following your program for your REST? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your Saunas or Heat Lamp? How closely have you been following your program for your Saunas or Heat Lamp? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your Spinal Twist? How closely have you been following your program for your Spinal Twist? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your Foot Rubs? How closely have you been following your program for your Foot Rubs? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your Coffee Enemas? How closely have you been following your program for your Coffee Enemas? 0 (not at all) 1 2 3 4 5 (perfectly)

How closely have you been following your program for your Skin Brushing? How closely have you been following your program for your Skin Brushing? 0 (not at all) 1 2 3 4 5 (perfectly)

Diet: What are examples of typical breakfasts for you? (Food and Beverages)

Diet: Mid-morning Snacks? (Food and Beverages)

Diet: What are typical lunches for you? (Food and Beverages)

Diet: Mid-afternoon Snacks? (Food and Beverages)

Diet: What are typical dinners for you? (Food and Beverages)

Diet: Evening Snacks? (Food and Beverages)

Describe changes you have noticed in your symptoms over the past several months.

Do you have any questions about your supplements?

Do you have any questions about emotional aspects, meditation or lifestyle challenges?

Are there other concerns you would like me to address when updating your healing program?

Joint Pain Joint Stiffness Arthritis, Osteo Arthritis, Rheumatoid Muscle Pain Muscle Weakness Muscle Cramps Bursitis Fractures Osteoporosis Gout

Sweet Cravings Sugar Reactions Irritable Before Meals Can't Skip Meals Hypoglycemia Crave Starches Fat Cravings Other Food Cravings Food Allergies Excessive Hunger No Hunger Diabetes

Rapid Heart Rate Skipped Heart Beats Heart Palpitations Heart Attack Poor Circulation Dizziness Low or High Blood Pressure Angina High Triglycerides

Arteriosclerosis High Cholesterol Cough Bronchitis Asthma Post-nasal Drip Sinus Congestion Allergies Emphysema

Fatigue Hypothyroidism Low Body Temperature Cold in Winter / Dry Skin Tend to Gain Weight Hyperthyroidism Acne Eczema

Fungal Infections / Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Meniere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease

Infections / Viruses Tumors / Cancer Multiple Sclerosis Parkinson's Disease Scleroderma Fear Anger Anxiety Bipolar Disorder Brain Fog Confusion Depression Irritablity Mind Races Mood Swings Obsessive / Compulsive Panic Attacks Poor Memory Schizophrenia Trouble Sleeping Suicidal Thoughts Autism Attention Deficit Hyperkinesis Dyslexia Seizures Learning Disability Mental Retardation Delayed Development

Bladder Infections Kidney Infections Trouble Urinating Frequent Urination Painful Urination Kidney Stones Water Retention Sinus Headaches Tension Headaches Migraine Hedaches

Neuritis Eye Diseases Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tend to Gain Weight Tend to Lose Weight

Anemia Easy Bruising

Dental Amalgams Drug Addiction Alcoholism Smoking

Premenstrual Syndrome Water Retention Cramps No Menstration Heavy Periods Light / Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocycstic Breasts Breast Tumors Yeast Infections Hot Flashes Currently Pregnant Abuse Rape

Prostate Problems Impotence Infertility

Vegetarian Vegan

698 RETEST ONLY - Emotionally Stronger 697 RETEST ONLY - Feeling About The Same 689 RETEST ONLY - Feeling Better 690 RETEST ONLY - Feeling Worse

Additional Comments or Symptoms

5 + 12 =

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