Nourish application form

Apply to join our program

This form should be completed by the person wanting to attend our program. Before completing it, please read the FAQ page on our website.
Name*

First NameLast Name
Email address*
Please check that you have entered it correctly.
Address*

House/Apt number & Street Address

Street Address Line 2

CityState / Province / County

Zip Code / PostcodeCountry
Phone number (including country code)*
For example +1 (202) 588-6500
Date of Birth*

MonthDayYear
What is your Gender?*

MaleFemale
Do you have the financial means to cover the cost of our program, as detailed in our FAQs? (We do not participate in any health insurance plans. In our experience, many insurance companies will not reimburse you for any part of our offering, including our fee, or any natural supplements, as referred to in the next question.)*

YesNo
In the event that you want to pursue the enzyme treatment of cancer, do you have the financial means to cover the cost of natural supplements, as detailed in our FAQs?*

YesNo
Are you prepared to take up to 150-200 capsules spread throughout the day, some with meals and some taken an hour or more away from food, with some taken in the middle of the night?*

YesNo
Do you have the motivation and commitment to follow a strict diet, plus a supplement and detoxification program, which includes coffee enemas?*

YesNo
Are you able and have the means to travel to Central Europe for a residential stay, to learn the enzyme treatment of cancer at our nutrition centre?*

YesNo
How tall are you? (please specify metres or feet & inches)*
e.g. 1.72m or 5'7"
How much do you weigh? (please specify lbs or kgs)*
e.g. 120 lbs or 55kg
What type of cancer have you been diagnosed with?*
On what date were you diagnosed?*

MonthDayYear
Is this your first cancer diagnosis?*

YesNo
Please describe the extent/stage of disease, including details of any recurrences*
Have you received any treatment?*

YesNo
Date of treatment (if applicable)

MonthDayYear
Please describe what treatment(s) you have received (if applicable)
Have you been recommended any treatment not yet received?*

YesNo
What type of treatment have you been recommended? (if applicable)
For example: Surgery, chemotherapy and/or radiation
Are you considering any other treatments?*

YesNo
What type of other treatments are you considering? (if applicable)
Have you had any previous interest in alternative medicine?*

YesNo
Describe how you feel about your current physician(s) and the care you've received*
We will not share any information with anyone.
Please provide details of any prognosis given to you by your physician or oncologist (or enter 'none provided') *
How has your cancer affected your daily life, activities, cognitive ability, ability to work and travel?*
Please describe how do you feel in yourself, health-wise*
Please describe any other health challenges you have now, or you've had in the past, even if you consider them to be minor e.g. hay fever or food/environmental allergies*
Are you currently taking any prescription medication?*

YesNo
Please list your current prescription medication(s), including dosing (or type 'none')*
Please describe any recent weight gain or weight loss*
Do you have any problems eating?*

YesNo
Please describe any appetite problems or reduced food intake (if applicable)
Do you have any problems drinking fluids?*

YesNo
Please describe any problems concerning drinking fluids (if applicable)
Do you have problems swallowing tablets/capsules?*

YesNo
Please describe any problems regarding swallowing tablets/capsules (if applicable)
Do you smoke tobacco?*

YesNoUsed to, but no longer smoke
Please describe your history of smoking (if applicable)
Do you drink alcohol?*

YesNo
Please indicate your current alcohol consumption (units per week) and include any history of alcohol problems (or enter '0')*
No information shall be shared with anyone.
How would you describe the support you've received from family and friends, with specific regard to you wanting to learn the enzyme treatment of cancer?*

I feel very well supportedThey have not offered any opinion on the matterI have no support from family or friendsThey are opposed my desire to follow this path
Please describe your faith/belief system*
We do not share your information with anyone.
Do you live alone?*

YesNo
Please describe your living circumstances, including the relationships who have with those you live with (e.g. spouse, parents,children)*
Please explain why you want to attend the Nourish program to learn the enzyme treatment of cancer*
Do you feel sufficiently well to travel to our location (central Europe)?*

YesNo
Do you require a wheelchair?*

YesNo
Please describe any physical or mental disability you have (if applicable)
How would you classify your current diet?*

Standard Western/American DietPaleoKetoVegetarianVeganCarnivorePescatarian
Have you changed your diet in response to your cancer diagnosis?*

YesNo
Please describe any changes you've made to your diet (if applicable)
How did you hear about Nourish?*
Please add any additional information which you believe to be relevant
After you submit your information

We will contact you within 48 hours, via email (please double check that the email address you entered above is correct). For most applications, we will ask you to send us copies of your medical records.
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Apply to join our program

After you submit your information