Your Name
(required)
Email
(valid email required)
Age
(required)
Phone number
(required)
1. What was the date your last HTMA was sent?
(required)
2. What supplements, and how many of each are you currently taking?
EG: Paramin 2-2-2
(required)
3. What type AND amount of water are you drinking
(required)
4. On a scale of 0-5, how closely have you been following your program? 0= not at all 5=perfectly.
Lifestyle
(required)
Diet
(required)
Supplements
(required)
Sauna or heat lamp
(required)
Coffee enemas
(required)
Pushing Down Exercise
(required)
Water
(required)
5. Please write the question in your own words. AND Please list your symptoms and how long you have had them. AND Include the severity.
(required)
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