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Client Information: Continued Page (3) of 9

Name Date

ABOUT YOUR BODY INC. - WELCOMES YOU!

  Full Name:
  Street Address:
  City/State/Zip:
  Phone Number:
  Place of Birth (City/State):
  Date of Birth:
  Who referred you:
Number of organs removed
Personal stress (1-10)
Number of synthetic drugs (Currently using) No. of sugar type products in a day (1-10)
Number of times you smoke in a day Number of exercise sessions in a week
Number of steroid type drugs (Used in the past year) Number of alcoholic drinks a day (avg.)
Number of amalgam (silver) Fillings in you mouth Number of caffeine products per day (coffee, tea, soda)
Number of street drugs used each month Number of toxic exposures (Radiation, chemicals, insecticides, etc...)
Number of all known allergies Number of major injuries in the past
Number of unresolved emotional factors (Anger, depression, anxiety, etc... ) Number of major infections in the past
I am responsible for my body (1-10) Number of glasses of water per day
Amount of fat in diet (1-10) How many pounds overweight
Amount of Negativity (1-10)