RETURNING Client Retest Information Form Name * First Name Last Name Address * City * State * Zip * Country * Phone Number (including area code) * Email Address * Sex * Male Female Age * Height * Weight * How well are you following the program? * Please answer the questions below to help us set up your new program. On a scale of 0-5, how closely are you following the program, 0 = not at all 5 = perfectly 0 1 2 3 4 5 Lifestyle * 0 1 2 3 4 5 Supplements * 0 1 2 3 4 5 Diet * 0 1 2 3 4 5 Drinking Water * 0 1 2 3 4 5 Sleep * 0 1 2 3 4 5 Sauna or Heat Lamp * 0 1 2 3 4 5 Foot Reflexology * 0 1 2 3 4 5 Coffee Enemas * 0 1 2 3 4 5 Meditation * 0 1 2 3 4 5 DIET: What is your current diet - Breakfast * Lunch * Dinner * Describe changes you have noticed in your symptoms over the past several months * Do you have any questions about your supplements, diet, sauna therapy, or coffee enemas? * Do you have any questions regarding the emotional aspects, meditation, or lifestyle challenges surrounding your program? * Are there other concerns you would like us to address when updating your healing program? * How many cups of cooked vegetables do you ear per day on an average? * Are you eating raw vegetables, and if so, how many servings per day? * Are you eating fruit, and if so, how many servings per day? (If yes, please include which fruits you are eating) * How many times a day do you eat animal protein? * None Once Twice Three or more Does this include red meat? * Yes No If you are eating red meat, how many times a week do you eat red meat? Once Twice Three or more Are you eating sugar? * Yes - frequently Yes - but infrequently Rarely - only on special occasions Never If you are eating sugar, do you still have sugar cravings? Yes No How many cups of complex carbohydrates (starches) do you eat daily? * Are you drinking juice? * Yes - Daily Yes - A few times a week No If applicable, what kind of juice are your drinking? How much water do you drink daily in ounces? * What type or brand of water are you drinking? * How many times a day do you take your supplements? * None Once Twice Three Please list ALL the supplements that you are taking and are part of your current program - Include the amounts - (i.e. Paramin 1/1/2) * Please list any supplements that are part of your Mineral Balancing Program but that you are NOT taking * Please list all supplements, herbs and medications that you are taking that are NOT part of your Mineral Balancing Program * Do you use any form of Near Infrared Light therapy - Check all that apply: * Near Infrared Light Near Infrared Sauna Neither If applicable - How many times a week do you use the Near Infrared Light or Sauna? If applicable, what is the average time of a typical Near Infrared Light/Sauna session? How many coffee enemas do you do daily? * None One Two More than two Are you doing meditation? * Yes - Everyday Yes - A few times a week Yes -Infrequently Not Currently If applicable, what type of meditation do you do? If applicable, how long is an average meditation session? How many hours do you sleep? * What time do you go to bed? * Do you exercise? * Yes No If applicable, at what intensity do you exercise? Hard Moderate Light If applicable, how many times a week do you exercise? How long is an average exercise session? List the types of exercises you do? Do you do deep breathing exercises, (aside from focused breathing during meditation)? * Yes No Do you perform the spinal twist? * Yes No Do you practice foot reflexology? * Yes No Do you have amalgam (mercury) fillings? * Yes No I don't know If you have amalgam fillings, are you having them removed? Yes No Have you completed the Toxin Sources and Symptoms Activity? * Yes No I don't know Have your removed sources of toxins from your life? * Yes No Partially If you have not removed toxins from your life, please list the remaining sources of toxins- (i.e. Mercury - Fish). Include use of marijuana and/or other drugs (Optional): Have you received the Covid Vaccine(s)? If yes please complete the next section. Option 1 Option 2 (Optional): Which Covid vaccine(s) did you receive? (Optional): Dates you received the Covid vaccine(s) How are you feeling? * Better About the same Worse Please expound below Please share what you find challenging and/or rewarding about your program? * Would you recommend the program to others? * Yes No Maybe Please expound below Please share anything I can do to serve you better * Symptoms Page Check all symptoms that presently describe you: 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 Blood Pressure 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 Tendency to Gain Weight Hyperthyroidism Eye Conditions Acne Eczema Fungal Infections/Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Menjere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease Infections/Viruses Epstein-Barr Virus 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 Suicidal Thoughts Schizophrenia Trouble Sleeping/Insomnia 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 Sinus Headaches Tension Headaches Migraines Headaches Neuritis Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tendency to Lose Weight Anemia Easy Bruising Dental Amalgams Abuse Drug Addiction Alcoholism Smoking WOMEN: Premenstrual Syndrome Water Retention Cramps No Menstruation Heavy Periods Light Periods Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocystic Breasts Breasts Tumors Yeast Infections Hot Flashes MEN: Prostate Problems Impotence Infertility Other Symptoms Please list any other symptoms you have, including eye conditions: Most Important Symptoms Please list the symptoms that are the most important to you: Additional Information You would like to share Please sign the waiver in the box below * I understand that nutritional balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease. All recommendations for supplements, products, or procedures, are not intended as treatment or prescription for any disease or as a substitute for medical care. All handouts or information dispersed during individual appointments or at workshops are the opinions of Doreen McCafferty, Nutrition and Lifestyle Consultant, unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked. This information is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Doreen McCafferty and her community. Doreen McCafferty encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional. Date * MM DD YYYY Thank you!
