Luke’s Retest Forms Page

Name
Age
Date
City
Post Code
Country
Home Phone
Business Phone
Email
On a scale of 1-5, how closely have you been following your program? 0=not at all, 5=perfectly
Diet
Please enter a number from 1 to 5.
Supplements
Please enter a number from 1 to 5.
Water
Please enter a number from 1 to 5.
Lifestyle
Please enter a number from 1 to 5.
Rest
Please enter a number from 1 to 5.
Sauna or heat lamp.
Please enter a number from 1 to 5.
Spinal Twist
Please enter a number from 1 to 5.
Foot Rubs
Please enter a number from 1 to 5.
Coffee Enemas
Please enter a number from 1 to 5.
Meditation
Please enter a number from 1 to 5.
Skin Brushing
Please enter a number from 1 to 5.
DIET: What are examples of typical breakfasts for you?
Beverages
What are typical lunches for you?
Beverages
What are typical dinners for you?
Beverages
Describe changes you have noticed in your symptoms over the past several months.
Do you have any questions about your supplements, diet program, sauna therapy or coffee enemas?
Do you have any questions about emotional aspects, meditation, or lifestyle challenges?
Are there any other concerns you would like us to address when updating your healing program?
I understand that Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease
- Yes
- No

On a scale of 1-5, how closely have you been following your program? 0=not at all, 5=perfectly