First Name:
Last Name:
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1. Which group of words most accurately describes your personality? You can choose only one, so pick the most applicable.
a) Sophisticated, Organized, and Put-Togetherb) Spontaneous, Trendsetter, and Confidentc) Direct, Independent, and Self Awared) Dependable, Friendly, and Relaxede) Sensitive, Empathetic, and Caringf) Laidback, Creative, and Eclectic
2. If someone were to peer into your accessory collection, what would they find? Choose the most accurate answer.
a) Pearls, simple stud earrings, chain necklaces, and sleek beltsb) Trendy, statement pieces, oversized sunglasses, and lots of blingc) Cuff bracelets, lots of metal, oversized rings, and one-of-a-kind findsd) Simple necklaces, small chain bracelets, natural shell jewelry, and a friendship bracelete) Vintage-inspired jewelry like charm bracelets, locket necklaces, and heart earringsf) Quirky and eclectic pieces, skull bracelets, snake rings, and an oversized pendant necklace
3. If you could choose any of the following outfits to have, free of charge, which would it be?
a) Striped cotton top, chino pant, skinny belt with matching leather tote bagb) Zippered romper, cropped motorcycle jacket, platform sandalsc) Black jumpsuit, silver statement necklace, midnight purple blazerd) Casual white jeans, chambray button-down shirte) Vintage-inspired dress with ruffles and gold heart charm braceletf) Bird print black dress, red cropped blazer, vintage sunglasses
4. Which answer best describes your current or dream shoe collection?
a) Simple pumps and riding bootsb) Platform sandals and designer sneakersc) Stilettos, knee-high boots, and patent leatherd) Slip-on loafers and simple sandalse) Vintage-looking oxford shoes and quilted flatsf) Colorful leathers and animal prints
5. If you won $1000 to spend anywhere, where would you go?
a) Nordstrom, Banana Republic, GAPb) Forever 21, ASOS, Topshopc) MaxMara, Bloomingdalesd) J.Crew, Old Navye) Anthropologie, ModClothf) Urban Outfitters, thrift shops
6. Which celebrities’ styles do you like best?
a) Victoria Beckham, Kate Middletonb) Blake Lively, Beyoncec) Charlize Theron, Kim Kardashiand) Jennifer Aniston, Kate Hudsone) Emma Watson, Taylor Swiftf) Nicole Richie, Rachel Bilson
7. If someone were to open your closet, what colors would they see?
a) Neutrals – black, whiteb) Bold – bright blues, redsc) Authoritative – Black, redd) Soft – neutrals, light greyse) Pastels – soft yellow, peachf) Everything – prints, neutrals
8. Which black pump would you wear?
a) Medium height, comfortableb) Platform with pointed heelc) Stiletto with red bottomd) Low, pointed heele) Black lace heelf) Thick-heeled platform
Name:
Age:
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Telephone (best):
Email:
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How many ounces of water/day?
What other beverages and how much?
Do you use artificial sweeteners?
Do you eat breakfast?
What is the first thing you do when you get up in the morning?
What time do you eat your first meal?
What time do you eat your last meal?
Do you exercise/move/participate in fun sweaty activity?
What time do you go to bed?
How long do you sleep?
Have you ever been in consultation with a naturopath? If so, why? How long ago?
What was suggested?
Did you experience a good outcome?
What did you like about it?
What wasn’t as successful for you?
Do you have regular adjustments with a chiropractor?
Do you have regular body work/massages?
Please check all with which you are familiar:
Homeopathy Bach Flowers/flower remedies Probiotics Aromatherapy Muscle response testing Herbals Sports nutrition Enzymes
RBTI Numbers:
Total Carbs:
pH:
Total Salts:
Cell Debris:
Ureas:
Total Ureas:
Eye Findings:
Face Findings:
Tongue Findings:
Nail Findings:
Active MRT Points:
Recommendations:
Next consultation recommended on:
I understand that I am here to learn about nutrition and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment, or prescribing of remedies for disease.
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