HTMA Retest Form

Your Name(required)
Email(valid email required)
Age(required)
State(required)
Country(required)
Phone number(required)
1. Please answer the questions below to help us design your new NB Program: On a scale of 0-5, how closely have you been following your program? 0= not at all 5=perfectly.
Diet(required)
Supplements(required)
Water(required)
Lifestyle(required)
Sauna or heat lamp(required)
Pushing Down Excercise(required)
Reflexology(required)
Coffee Enemas(required)
Spinal Twist(required)
Sleep(required)
Rest(required)
2. What is your current diet? Please be honest- I know it can be embarrassing)
Breakfast(required)
Lunch(required)
Dinner(required)
Snacks(required)
Beverages(required)
3. Describe changes you have 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 any other concerns you would like us to address when updating your healing program?
Disclaimer: Nutritional Balancing is a means to reduce stress and is not intended as diagnosis. treatment or prescription for any condition or disease. (Sari Young Naturopath)