Client Question Form Name * First Name Last Name Age * City * State * Zip * Country * Phone (including area code) * When was your last Hair Analysis (month/year)? * List the supplements you are currently taking, including anything that is not part of your program: * What medications are you currently taking? * What type and how much water are you drinking? * How well are you following your program - Use 0 - 5, with 0 = not at all to 5 = perfectly * 0 1 2 3 4 5 Lifestyle * 0 1 2 3 4 5 Diet * 0 1 2 3 4 5 Supplements * 0 1 2 3 4 5 Water * 0 1 2 3 4 5 Sauna * 0 1 3 4 5 Coffee Enemas * 0 1 2 3 4 5 Mental Exercise/Meditation * 0 1 2 3 4 5 Please precisely share your question(s) below: * Thank you!
