Please read, fill-out, sign and submit
Must avoid completely during treatment
Dairy Products: Milk (from cows)
Other Dairy Products (from cow) such as cheese, yogurt, etc.
Please check any items on this list that you will consume during the period of nutritional treatment regimen. We may recommend you avoid them if you are able.
Added Salt (other than prepared foods)
Products with added Vitamins, nutrients
(ex: enhanced orange juice with added calcium, etc)
Do you smoke cigarettes?
Do you smoke (anything else)?
Coffee
Tea (circle) Black Green Herbal Other ______________
List type of water (water info link) you consume typically and name brand
(Please try to drink Purified water during treatment)
Tap
Spring
Drinking
Purified
Distilled
Please list all nutrition you will be taking during nutritional treatment regimen: Nutritional supplements (including green drinks and powdered supplements), herbs/herbal formulas, and prescription medications.
Upon completion of the nutritional regimen, you will be asked "What are you symptoms/how do you feel today?" again.
Thank you for the opportunity to help you improve your health.
(NHSTM) Compliancy ContractI hereby agree to comply (to follow the instructions on a daily basis) with the nutritional regimen recommended, for the period of ___________ which includes weekly follow-up scans, to verify current or issue new nutrition regimen.
During your contract should you have any questions or concerns, please contact your issuing Physician immediately
Name: ________________________Signature ____________________________ Date __________
email this information to: pahner@healingx.org