Retest analysis

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Retest Intake Form

Nutritional Balancing by Whole System Healing
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Weight *
Height *
Age *
Please answer these questions truthfully to help us set up your new program
On a scale of 0-5, how closely have you been following the program? 0=not at all 5=perfectly
Diet
Supplements
Water
Lifestyle
Rest
Saunas or heat lamp
Spinal Twist
Foot Rubs
Coffee Enemas
Meditation
WHAT IS YOUR CURRENT DIET - (BE HONEST - THIS IS TO BEST HELP YOU AND DETERMINE WHAT YOU NEED)
YOUR TYPICAL BREAKFAST FOODS *
YOUR TYPICAL BREAKFAST BEVERAGES *
YOUR TYPICAL LUNCH FOODS *
YOUR TYPICAL LUNCH BEVERAGES *
YOUR TYPICAL DINNER FOODS *
YOUR TYPICAL DINNER BEVERAGES *
DESCRIBE CHANGES YOU HAVE NOTICED IN YOUR SYMPTOMS OVER THE PAST 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, LIFESTYLE CHALLENGES? *
ARE THERE OTHER CONCERNS YOU WOULD LIKE US TO ADDRESS WHEN UPDATING YOUR PROGRAM? *
SYMPTOMS LIST

Select any conditions or symptoms that presently describe you
Symptoms list 1

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 Arteriosclerosis High Cholesterol High Triglycerides 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
Symptoms list 2

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 Irritability 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 Kidney Stones Water Retention
Symptoms list 3

Sinus Headaches Tension Headaches Migraine Headaches 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
Symptoms Specific to Women

Premenstrual Syndrome Water Retention Cramps No Menstruation Heavy periods Light/Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocystic Breasts Breast Tumors Yeast Infections Hot Flashes Currently pregnant Abuse Rape
Symptoms Specific to Men

Prostate Problems Impotence Infertility
Other Symptoms
CONSENT & DISCLOSURE
I request that Melissa Navarro/Julien Griffault perform a nutritional evaluation and set up a diet, supplement, detoxification and lifestyle program for the purpose of enhancing health and improving well-being. I understand that all testing, techniques and supplements are recommended/provided for the purpose of reducing stress and balancing body chemistry. None of the services/products recommended or provided are intended as diagnosis, prevention, treatment or prescription for any mental or physical disease, and are not intended as substitute for regular medical care.

I authorize Analytical Research Labs of Phoenix, Arizona to perform a hair mineral analysis of my hair sample (if given). I further authorize the sharing of my personal information, analysis and/or other testing results with Dr. Lawrence Wilson, and/or any other advanced health practitioner Melissa Navarro/Julien Griffault may consult for the purpose of designing my nutritional program.
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PAYMENT OPTIONS
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If you would prefer to send a check, select that option. Please make your check out to healingaia and include it with your hair sample.

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Hair Analysis Retest $ 150.00
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Retest Intake Form

Please answer these questions truthfully to help us set up your new program

SYMPTOMS LIST

CONSENT & DISCLOSURE

PAYMENT OPTIONS