Initial Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### I understand that Mineral-Nutritional Balancing is a means to reduce stress, strenghten and balance body chemistry. When this is done, many health conditions improve on their own. Nothing here is intended to discourage anyone from seeking or following the advice of a medical doctor. This is not meant to diagnose, treat or cure any diseases and isn’t a substitute for standard medical care. I understand that participation in this program can activate a variety of physical, emotional and psychological responses. I hereby take full responsibility for my participation in this program and for any consequences resulting from my participation. * Sign or Type your Name: Date * MM DD YYYY What are your main health concerns or conditions? List any symptoms and where they occur Write the details of your health history starting when you can remember feeling well and on from there. Include any vaccinations, illnesses and trauma, and their approximate dates What medications and/or supplements are you currently taking? Include botox/dyport if using now or used in the past List any 'out of range' (high or low) results from recent medical tests (e.g. blood tests) List illnesses in your immediate family (e.g. heart disease, cancer, TB, diabetes, arthritis) What kind of movement/excercise do you do and how often? Approximately how many hours of sleep do you get each 24h and what is the quality? List therapies, diets, supplements, medications etc. that you have found helpful List therapies, diets, supplements, medications etc. that haven't worked well for you List any alcohol or recreational drug use (including marijuana), amount and frequency What is your typical: breakfast including bevarages? What is your typical: mid-morning snack? What is your typical: lunch including bevarages? What is your typical: mid-afternoon snack? What is your typical: dinner including bevarages? What is your typical: evening snack? Carnivore Keto Low-carb Paleo Pescetarian Vegan Vegetarian Health Issues & Life Experiences Questionnaire 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 hyperthyroidism infection – bacterial infection – fungal (e.g. Candidiadis) infection – urinary tract infection – viral infertility intestinal gas irritability 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 – high 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 impotence prostate problems Female 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 Trauma abuse – emotional abuse – physical abuse – sexual Comments Thank you!
