Cancer Nutrition Program Application Form

Application form

This form should be completed by the person wanting to take part in Matt's program. Before completing it, please read the FAQs on his website. Please note that Matt's program is available in the USA only.
Name *

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

House Number & Street Address

Address Line 2 (optional)

City State

ZIP Code
Phone number *
e.g. (202) 588-6500
Date of Birth *

Month Day Year
What is your Gender? *

Male Female
Do you have the financial means to cover the cost of Matt's program, as detailed in the FAQs? (Matt does not participate in any health insurance plans. Experience shows that many insurance companies will not reimburse you for any part of his offering, including his fee, or any natural supplements, as referred to in the next question.) *

Yes No
Do you have the financial means to cover the cost of natural supplements, as detailed in the FAQs? *

Yes No
Do you have the motivation and commitment to follow a strict diet, plus a supplement and detoxification program, which includes coffee enemas? *

Yes No
Are you prepared to take up to 150 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? *

Yes No
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? *

Month Day Year
Is this your first cancer diagnosis? *

Yes No
Please describe the extent/stage of disease, including details of any recurrences *
Have you received any treatment? *

Yes No
Date of treatment (if applicable)

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

Yes No
What type of treatment have you been recommended? (if applicable)
For example: Surgery, chemotherapy and/or radiation
Are you considering any other treatments? *

Yes No
What type of other treatments are you considering? (if applicable)
Have you had any prior interest in alternative medicine? *

Yes No
Please describe how you feel about the care you've received from your current physician(s) *
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, digestive problems *
Are you currently taking any prescription medication? *

Yes No
Please list your current prescription medication(s), including dosing (or type 'none') *
Are you currently taking any natural supplements? *

Yes No
Please list your current natural supplements, including dosing (or type 'none') *
Please describe any recent weight gain or weight loss *
Do you have any problems eating? *

Yes No
Please describe any appetite problems or reduced food intake (if applicable)
Do you have any problems drinking fluids? *

Yes No
Please describe any problems concerning drinking fluids (if applicable)
Do you have problems swallowing tablets/capsules? *

Yes No
Please describe any problems regarding swallowing tablets/capsules (if applicable)
Do you smoke tobacco? *

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

Yes No
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 supported They have not offered any opinion on the matter I have no support from family or friends They are opposed to the idea of me following this approach
Please describe your faith/belief system *
We do not share your information with anyone.
Do you live alone? *

Yes No
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 learn Matt's program *
Please describe any physical or mental disability you have (if applicable)
How would you classify your current diet? *

Standard Western/American Diet Paleo Keto Vegetarian Vegan Carnivore Pescatarian
Have you changed your diet in response to your cancer diagnosis? *

Yes No
Please describe any changes you've made to your diet (if applicable)
How did you hear about Matt? *
Please add any additional information which you believe to be relevant
After you submit your information

Matt will contact you within 48 hours, via email (please double check that the email address you entered above is correct). For most applications, Matt will request copies of your medical records.
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Application form

After you submit your information