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  • Moses Nutrition Repeat Hair Analysis

    Progress Update and Information Form

  • It's great you're doing your retest! This is a good time for us to review how you are doing with everything and to see what changes have occurred. Please type your answers into the form below (do not print and mail to us). Fill in all three pages thoroughly and hit the "Submit" button at the end to send it to us. All information is strictly confidential and is transmitted via SSL encryption.

  • Do you have any changes to your address, email or phone number?*

  • Please update any of the information below that has changed:

  • Format: (000) 000-0000.
  • Gender*
  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
  • On a scale of 0-5, how closely have you been following your program recommendations in the following areas?*
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  • Are you doing coffee enemas?*
  • Are you napping during the day?*
  • Have you noticed any positive changes in your symptoms since your last hair test?*
  • Have you noticed any negative changes in your symptoms since your last hair test?*
  • Are there any particular symptoms you are especially concerned about, or is there anything else you would like us to spend more time addressing when we go over your retest with you?*
  • Do you have any questions about any aspect of your program recommendations?*
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  • Details on your current diet:

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  • Tell us about your current symptoms:

  • Please look through all of the symptoms below and rate any you have experienced within the last couple of months, including symptoms you have had for a long time and are still experiencing. We are looking for changes since your last hair test, so DO NOT rate symptoms you no longer have. LEAVE THE SYMPTOM BLANK if that symptom does not apply to you. There is room at the end of this section for additional comments and symptoms.

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  • Have you had any of the following since your last test?
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  • Do any of these currently apply?
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  • Men
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  • Women - Part 1
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  • Women - Part 2
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  • Will you be mailing in your hair sample or coming in to have us cut it for you?*

  • You may have already received in the mail a hair sampling kit with a scale to weigh the sample so that you know exactly how much hair to send.  If you have not received this kit, or if you need another, we can mail one to you.

  • (This kit is not necessary; you may simply fill a kitchen tablespoon with the hair.)*
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  • When we receive your hair sample in the mail, we will email you to let you know it arrived safely. We will also send you a link to book your test results appointment. You can choose to do it either by phone or in the office (if you are local, we recommend doing it in person if possible).

  • Prior to your test results consultation, we will be sending you a packet of written information that includes your test results, an introductory explanation of your results and your program recommendations. This gives you time to review the materials prior to our consultation. We prefer to send this packet by email. If for some reason you cannot receive your information via email, please contact us to make other arrangements.

  • When you hit 'Submit' below, you will be provided a link to a pdf version of your filled-in form that you can use to view, save, and print a copy of your form submission. You also have the option to additionally receive an email with a copy of this form with all of your answers (for added privacy, your name, address and phone number will not be included in the email). Note: this is a standard email, and the data will not be encrypted. Please select:*

  • Thank you so much! If you do not receive the email with the copy of your form, be sure to check your junk mail. If you think of new information you would like to share with us, you can send it to us by replying to that email or by emailing us via our website. Please call us or use our online scheduling at our website to book any appointments, such as a hair-sampling visit or your test results consultation. We look forward to going over your retest with you!

  • Thank you so much! If you think of new information you would like to share with us, you may email us via our website. Please call us or use our online scheduling at our website to book any appointments, such as a hair-sampling visit or your test results consultation. We look forward to going over your retest with you!

  • Don't forget to hit Submit below when done.

  • Have a happy and healthy day!

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