INITIAL HAIR ANALYSIS FORM

INITIAL HAIR ANALYSIS FORM

Copyright 2014 Eileen Durfee
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MonthDayYear
Website Order ID*
Full Name*

First NameLast Name
Sex*
Age*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone*
Alt. Phone
Skype
Height
Weight
Occupation
Prior Hair Analysis?
Previous Lab Number
What are your main health concerns or conditions?
Please list any medications or food supplements you are currently taking:
Please list any RECENT medical test results you have, i.e. blood tests, etc or state none:
Please list illnesses in your family such as heart disease, cancer, TB, diabetes, arthritis, etc.:
Breakfast and Beverages:
Mid Morning Snack and Beverages:
Lunch and Beverages:
Evening Snack and Beverages:
Exercise: How often and what kind?
Sleep and issues: How many hours of sleep per day?
Are you willing to modify your diet and lifestyle or just take supplements?
Please provide us with your CURRENT symptoms or if you would like to tell us anything else use this area:
Name of other person you authorize us to talk to about your program and hair analysis:
E-mail address and contact information of authorized person:
Signature

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