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?

Rows	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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