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HEALER'S SURVEY

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Ple ase If Yo u Are A Cust o m e r Of Mine I Wo uld Lo ve If Yo u Wo uld He lp Me Out By Filling Out My He ale rs Surve y...Yo u Be ing T he He aly T his Is Ve ry Im po rt ant , Be cause Mo st Like ly T he Only Re aso n Yo u Trust e d Me Truly In T he First Place , Is Be cause Yo u He ar T he Wo rd Of Mo ut h Abo ut Ho w I Am Curing Pe o ple Le f t And Right , So No w I Am Est ablishing So m e t hing Eve n Mo re Addit io nal Wit h T he PERFECT IONAL PRACT ICE As I Am Go ing To Ne e d Yo ur Co m ple t e And Since re Co o pe rat io n Wit h m e No w...I Ne e d Yo u To Answe r T he se So We Can HELP SAVE T HE WORLD, As I Pro m ise d Be f o re , T OGET HER. We Can Do T his, I J ust Ne e d Yo ur He lp No w, Can Yo u He lp Me ? It Only Will Take Te n Minut e s To p..Ple ase J ust Answe r And Put Yo ur Nam e - Em ail (If Yo u Want ) - And Age - (If Yo u Want ) And What Pro ble m s Yo u Had Be f o re And If Yo u St ill Have T he m Or If Yo u Do n't No t ice T he m As Much Or If T he y Are COMPLET ELY GONE....And He re Le t s J um p Int o T he Re st , Le t s Do T his, Alright ? ________________________________________________ HEALER'S SURVEY -NEW INST IT UT ION OF NUT RIT ION *PICK ONE OR AS MANY T HAT APPLY: ____________________________________

1.) Ene rgy le ve l: 10=Exce lle nt , 1=Po o r

2.) He ad: I am pale I have a re d f lushe d co m ple xio n My che st has a re d f lush t o it 8I ge t he adache s

3.) T he clim at e se e m s t o m ake m y co ndit io n wo rse whe n:

It 's ho t It 's dam p It 's co ld Clim at e change s do no t af f e ct m e It 's dry

4.) Sle e p: Tro uble f alling asle e p Tro uble st aying asle e p I wake in t he m iddle o f t he night I have vivid dre am s

I sle e p m o re t han 10 ho urs a day I t ake sle e p m e dicat io ns I f e e l anxie t y whe n I t ry t o sle e p

5.) Subje ct ive Bo dy Te m pe rat ure :

I have night swe at s I f e e l warm m o st o f t he day I use m ult iple blanke t s whe n I sle e p I pre f e r t o we ar swe at e rs He at m ake s m e f e e l t ire d My hands and f e e t are always co lde r t han t he re st o f m y bo dy I f e e l chille d m o st o f t he t im e

6.) Appe t it e /T hirst :

I pre f e r chille d be ve rage s I am hungry all t he t im e I have ble e ding gum s I have bad bre at h I am o ve rwe ight I am unde rwe ight I pre f e r warm be ve rage s I do n't have m uch o f an appe t it e

7.) Dige st io n: Lo o se St o o ls:

Af t e r e at ing Whe n I wake up Fo ul sm e lling Undige st e d f o o d part icle s Mult iple m o ve m e nt s t hro ugho ut t he day Co nst ipat io n Blo at ing Be lching Flat ule nce Vo m it ing Nause a

Pain in t he diaphragm are a St o m ach pain Acid re f lux

8.) Elim inat io n: Fre que nt dayt im e urinat io n Fre que nt night t im e urinat io n Cle ar pro f use urinat io n Dark/ punge nt sm e lling urinat io n Kno wn Pro st at e pro ble m s

9.) Skin & Nails: Dry/f laky skin Oily skin It chy skin Acne Rash Dry hair Gre asy hair T hinning hair Balding Dry/f laky f inge r nails Fungus o n t o e nails Lipo m as Varico se ve ins Live r spo t s

10.) Eye s: Cat aract s Dry e ye s Glaco m a Re d/blo o d sho t e ye s Wat e ry e ye s/discharge It chy re d e ye s Lo o sing e ye sight Eye sight lo ss

11.) Ears: De af Chro nic e ar inf e ct io ns wit h sm e ll Se nsit ive t o no ise Chro nic e ar inf e ct io ns wit ho ut sm e ll He aring lo ss

12.) Lungs: Ast hm a Wo rse wit h inhalat io n Wo rse wit h e xhale

Chro nic co ugh We t Dry Alle rgy re lat e d Flu re lat e d I have lo t s o f phle gm I sm o ke

13.) No se : Nasal co nge st io n wit ho ut m ucus Nasal co nge st io n wit h m ucus Cle ar m ucus Gre e n m ucus Ye llo w m ucus Dry no se It chy no se Sne e zing Nasal co nge st io n t hat o ccurs se aso nally

14.) What se aso n wo rse ns yo ur co ndit io n?:

Wint e r Spring Sum m e r Fall All se aso ns

Co m m e nt :

15.) Em o t io ns:

Aggre ssive Lo t s o f ange r/sho rt t e m pe re d Re st le ss Wit hdrawn: pre f e r t o be alo ne Anxio us De pre sse d Cry f re que nt ly I t ake ant i-de pre ssant m e dicat io ns

16.) Pain: Lo cat io n He ad Ne ck Sho ulde rs Uppe r back Lo we r back Hips Kne e s Elbo ws Wrist s Finge rs To e s

Bursit is? Te ndo ns pro ble m s (t e ll t he lo cat io n be lo w)

Go ut ? Do ct o r has said yo u have art hrit is? Do ct o r has said yo u have R.A.?

T he t ype o f pain can be de scribe d as: Dull Aching Sharp/st abbing Wo rse wit h m o ve m e nt Be t t e r wit h m o ve m e nt

I have swe lling aro und t he jo int s

I have re dne ss aro und t he jo int s Co ld m ake s it wo rse He at m ake s it wo rse Dam p we at he r m ake s it wo rse

Do yo u have we akne ss o f t he lo we r back? Do yo u have we akne ss o f t he kne e s?

Whe n did t he pain st art ? Do e s anyt hing m ake it be t t e r? Do e s anyt hing m ake it wo rse ? Co m m e nt :

Clie nt Nam e : Age : Se x: Se ve rit y: (10=Ve ry Se ve re ) We ight : What is yo ur m ain co m pliant t o day? Ho w lo ng has it be e n a pro ble m ?

List all m e dicat io ns and supple m e nt s yo u are t aking: List all he rbs t hat yo u are t aking? What m e dical diagno se s have yo u re ce ive d? Re vie w o f syst e m s: Do yo u have high blo o d pre ssure ? Do yo u have any pro ble m s wit h yo ur He art ? Do yo u have pro ble m s wit h yo ur Live r? Do yo u have pro ble m s wit h yo ur Kidne ys? Do yo u have ne uro lo gical pro ble m s?

Whe n Did Yo u START Fo llo wing Mr.Plo t t 's Pro t o co l?

Whe n Was T he Dat e Yo u No t ice d A Change ? -Was It Be t t e r Or Wo rse ?

Did Mr.Plo t t 's Pro t o co l Alle viat e Yo ur Issue s Or Pro ble m s Mo de rat e ly, Co m ple t e ly, Or No t At All?

What Was T he Pro t o co l Mr.Plo t t Assigne d To Yo u?

SIGNAT URE:

~E.G.Plo t t ~ Pe rf e ct io na Pract ice

PLEASE INCLUDE T HE FOLLOWING AND SEND T O e ricplo t t @ ho t m ail.co m Or m ail t o us. Yo u can Mr. Plo t t On Face bo o k He re : ht t ps://www.f ace bo o k.co m /blaze 573

Clie nt First Nam e :

Last Nam e :

Em ail Addre ss:

Re t ype Em ail Addre ss:

Pho ne # :

Ce ll/Night im e Te l # :

Be st T im e t o Call:

Pre f e r Pho ne call o r Em ail: By Pho ne By Em ail Have yo u e ve r wo rke d wit h he rbs be f o re ?

Ple ase t e ll us what que st io ns o r co nce rns yo u m ay have so t hat we m ay he lp yo u purchase o ne o f o ur f o rm ulas:

What is yo ur st at e ? We wo uld like t o kno w whe re yo u are lo cat e d t o be able t o call yo u at t he right t im e :

If o t he r ple ase t e ll us whe re o t he r is: Final co m m e nt s: Ple ase t e ll us anyt hing yo u f e e l t hat has no t be e n aske d:

Ho w did yo u f ind us?

If o t he r ple ase t e ll us who o t he r is:

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