Retest Form

Date

Name*

Age*

City, State

Street Address

Street Address Line 2

CityState / Province

City*

State*

Country*

Postal Code*

Phone Number*

Height*

Weight (lbs)*

Type of hair used*

HeadBeardPubicOther

Current Medications:

Please answer the questions below to help us set up your new program:

1. On a scale of 0-5, how closely have you been following your program? 0=not at all 5=perfectly

Diet*

Supplements*

Water*

Lifestyle*

Rest*

Heat lamp*

Sauna*

Reflexology*

Coffee Enemas*

Spinal Twist*

Meditation*

How many hours do you sleep each night?

2. What is your current diet? Please list actual foods.

Breakfast

Lunch

Supper

Beverages (please share type and brand of water):

3. Describe changes you have you noticed in your symptoms over the past several months.

4. Do you have any questions about your supplements, diet program, sauna therapy or coffee enemas?

5. Do you have any questions about emotional aspects, meditation or lifestyle challenges?

6. Are there other concerns you would like us to address when updating your program?

Which do you prefer when your test results are ready?

Audio Recording (review of your test results and program)Phone Consultation (15-20 Minutes)

Consent, Disclaimer and Disclosure

I request that Brian Brezinski perform a nutritional evaluation and set up a diet, supplement, detoxification, and lifestyle program for the purpose of enhancing health and improving well-being. I understand that all testing, techniques and supplements are recommended/provided for the purpose of reducing stress and balancing body chemistry and that Brian Brezinski is providing these services as an unlicensed nutrition consultant. None of the services/products recommended or provided are intended as diagnosis, treatment or prescription for any mental or physical disease, and are not intended as substitute for regular medical care.

E-mail

Please continue to the SYMPTOMS CHECKLIST on the next page.

RETEST INTAKE FORM

Symptoms Sheet