RETEST HAIR ANALYSIS FORM for Dr. Lawrence Wilson Copyright 2014 Eileen Durfee, NC

RETEST HAIR ANALYSIS FORM

Today"s Date*

Date

E-mail*

Web site Order ID #:*

Name*

Country*

Age*

Address*

Postal Code*

City*

State/Province*

Best Contact Phone*

Alternate Phone

Skype

Occupation*

Height*

Weight*

Sex*

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:

On a scale of 0-5, how closely have you been following your program? 0=Not at all 5=Perfectly?

	0	1	2	3	4	5
Diet
Supplements
Water
Lifestyle
Rest/Sleep
Saunas or Heat Lamp
Spinal Fitness
Foot Massage
Coffee Enemas
Meditation
Skin Brushing

What is your current diet? (Please don't fudge on this - I know it can be embarrassing):*

Describe changes you have noticed in your symptoms or condition over the past months:*

Do you have questions regarding your supplements, diet program, sauna therapy or coffee enemas?*

Do you have any questions in regard to any mental or emotional aspects, meditation or lifestyle challenges?*

Are there other concerns you would like to address when updating your healing program?*

Are there any changes in your medical history or medication over the past several months?*

Please provide us with your CURRENT symptoms or if you would like to tell us anything else, use this area:

I understand that body mineral balancing is a means to reduce stress and balance body chemistry, that Eileen Durfee is providing services as a Body Mineral Balancing and Lifestyle Coach, and that she is a Minister with a Diploma in Nutritional Balancing Science. Testing and consultations performed are not intended as diagnosis, treatment, or prescription for any condition or disease.

Client Name or Parent for Child*

After signing, you must click the SUBMIT buttion in order for the form to be processed.

*** IF YOU ARE SUBMITTING A PRINTED COPY OF THIS FORM, PLEASE FAX IT TO US AT (866) 370-7199. DO NOT MAIL IN YOUR FORM WITH THE HAIR SAMPLE. IT WILL NOT COME TO US.

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