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Question Inquiry Form
Your Name
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1. What was the date your last HTMA was sent?
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2. What supplements, and how many of each are you currently taking?
EG: Paramin 2-2-2
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3. What type AND amount of water are you drinking
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4. On a scale of 0-5, how closely have you been following your program? 0= not at all 5=perfectly.
Lifestyle
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Diet
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Supplements
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Sauna or heat lamp
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Coffee enemas
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Pushing Down Exercise
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Water
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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.
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