Hair Tissue Mineral Analysis Retest Questionnaire Name(Required) First Last AgePhoneEmail(Required) On a scale of 0-5, how closely have you been following your Personalized Active Care Plan? 0 = not at all, 5 = doing well Diet 0 1 2 3 4 5 N/A Dry Skin Brushing 0 1 2 3 4 5 N/A Coffee Enema 0 1 2 3 4 5 N/A Meditation 0 1 2 3 4 5 N/A Sauna / Sauna Light 0 1 2 3 4 5 N/A Supplements 0 1 2 3 4 5 N/A Sleep 0 1 2 3 4 5 N/A Describe changes you’ve you noticed in your symptoms or condition since you began your Personalized Active Care Plan.Do you have questions about your supplements and detoxification procedures?Is there anything interfering with your ability to follow the program?Is there anything else you want me to know as I update your Personalized Active Care Plan?DietWhat are examples of typical breakfasts for you (including beverages)?Mid-morning snacks?What are examples of typical lunches for you (including beverages)?Mid-afternoon snacks?What are examples of typical dinners for you (including beverages)?Evening snacks?Health Issues & Life ExperiencesSymptoms / Conditions Acne Addiction - alcohol Addiction - other substances Addiction - other Allergies - other than food Anemia Anger Angina Anxiety Arteriosclerosis Arthritis - osteo Arthritis - rheumatoid Asthma Attention deficit disorder Autism Bipolar disorder Bladder infections Bloating Blood pressure - low Blood pressure - high Body temperature - low Brain fog Bronchitis Bruising - easy Bursitis Cataracts Cholesterol - high Cholesterol - poor Cirrhosis Cold - feeling of Colitis Confusion Constipation Cough Depression Dermatitis Development - delayed Diabetes Diarrhea Diverticulitis Dizziness Dyslexia Eczema Emhysema Eyes - glaucoma Eyes - macular degeneration Fatigue Fear Fissures Food - allergies Food cravings - fats Food cravings - starches Food cravings - sweets Food cravings - other Food - can't skip meals Fractures Gall stones Gout Hair loss Headaches - migraine Headaches - sinus Headaches - tension Heart attack Heart - atrial fibrillation Heart -palpitations Heart rate - rapid Heartburn Hemorrhoids Hives Hunger - excessive Hunger - little to none Hyperkinesis Hyperglycemia Hyperthyroidism Hyperglycemia Hyperthyroidism Hypoglycemia Hypothyroidsm Infection - bacterial Infection - fungal / candida Infection - urinary tract Infection - viral Infertility Intestinal gas Irritability Irritability - before meals Joint pain Joint stiffness Kidney infections Kidney stones Learning disability Memory - poor Meniere's disease Mind racing Mood swings Multiple sclerosis Muscle - cramps Muscle - pain Muscle - weakness Neuritis Obsessive / Compulsive Osteoperosis Panic attacks Parkinson's disease Postnasal drip Psoriasis Schizophrenia Scleroderma Seizures Sinus - congestion Sleep - insomnia Sleep - disturbance Smoking Stomach pain Sugar reactions Suicidal thoughts Teeth - decay Teeth - dental amalgams Teeth - excessive plaque Teeth - gum disease Triglycerides - high Tumors / Cancer Ulcer Urination - frequent Urination - painful Vertigo Water rentention Weight - tend to gain Weight - tend to lose Wound healing -slow Men: Impotence Prostate Problems Women: Breasts - fibrocystic Breasts - tumors Cramps Fibroid Tumors Hot Flashes Menopause Menstruation - none Menstruation - heavy Menstruation - irregular Menstruation - light Ovarian cysts Pap smear - abnormal Pregnant - currently Premenstrual Syndrome Water retention Yeast Infection Comments
