1 Body Health LLCNew Clients #2

First name

Last name

QUESTIONS BELOW

HEAVY METALS

Do you have dental work such as a filing, crown, bridge etc?

Do you now or ever worn dental braces?

Do you use medication?

Have you been immunized?

Do you drink beer?

Do you use fluoridated tooth paste?

Do you smoke?

Do you have any artificial joints?

Do you have any tattoos?

Do you use anti-perspirant?

Do you drink water from a well?

FOOD SENSITIVITY

Do you eat the same food over and over?

Do you eat a lot of boxed foods (Dollar menu)?

Do you eat cheaper foods?

Have you been diagnosed with Celiac Disease or have a gluten sensitivity?

Do you eat wheat, rye, oats, barley, or spelt?

Do you eat more conventional foods vs organic foods?

Do you eat grocery store cheese?

Do you eat grocery store eggs?

Do you drink grocery story milk?

INTERFERENCE FIELDS

Do you have any old injuries that are not healed?

Do you have any surgery marks/scars on your body?

Do you have any tattoos on your body?

Do you wear a lot of black clothing?

EMOTIONS / SPIRITUAL

Have you ever experienced the death of a spouse, child, parent, a pet etc that still bothers you?

Do you have stress at work?

Do you have stress at home?

Do you have a stressful relationship?

If divorced, do you still experience any negativity?

Do you believe in God?

Did you have a negative religious experience growing up?

HOME ENVIRONMENT

CHECK OFF IF YOU EAT THESE FOODS

Animal meat

Well done meat

Flavored milk

Milk

SLEEP - Check if these statements apply to you

I can fall asleep easy?

I can sleep all the way till morning?

I use an electric blanket during cold months?

I sleep with a light / TV on?

I use sleep medicines / supplements?

OXYGEN - Check if these statements apply to you?

I smoke daily?

I smoke socially?

I live with someone who smokes?

I use steroid, diuretic, or heart meds?

BODY ALIGNMENT - Check if these statements apply to you?

STRESS - Check if these statements apply to you?

How would you rate your THOUGHTS / BELIEFS on an average basis? (1=negative thoughts; 10 = positive thoughts)

How would you rate your WORDS on an average daily basis 1 to 10? (1=negative thoughts; 10 = positive thoughts)

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