HAIR TISSUE MINERAL ANALYSIS FOR BALANCING BODY CHEMISTRY
GENERAL INFORMATION SHEET FOR NUTRITIONAL BALANCING - Part 1
SEX: M F
What are your main health concerns or conditions?
Please list any medications or food supplements you are currently taking:
Please list any recent medical tests results you have, such as blood tests:
Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis.
DIET - Part 2
What are examples of typical breakfasts for you? Beverages?
What are typical lunches for you? Beverages?
What are typical dinners for you? Beverages?
How often and what kind of exercise do you do?
About how many hours of sleep do you get per day?
SYMPTOM CHECKLIST - Part 3
SYMPTOM CHECKLIST - Part 3 Continued