Retest Form Name * First Name Last Name Email * Phone (###) ### #### On a scale of 0-5, how closely have you been following your Personalized MB program? 0 = not at all 5 = doing well Diet 1 2 3 4 5 Supplements 1 2 3 4 5 Sleep 1 2 3 4 5 Coffee Enema 1 2 3 4 5 Sauna/Sauna Light 1 2 3 4 5 Meditation 1 2 3 4 5 Reflexology 1 2 3 4 5 Rest 1 2 3 4 5 Describe changes you’ve noticed in your symptoms or condition since you began your MB program. 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 MB program? What is your typical: breakfast? What is your typical: mid-morning snack? What is your typical: lunch? What is your typical: mid-afternoon snack? What is your typical: dinner? 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!
