New Client Information Form for Adults

New Client Form – for Adults, 18 Years and over
Please type your answers into the form below (do not print and mail to us). Be sure to fill in all three pages thoroughly and sign on Page 4, then hit the "Submit Form" button at the end to send your completed form to us. All information is strictly confidential and is transmitted via SSL encryption. Please note: if you have a serious health condition such as cancer, Parkinson's, organ transplants, etc. please contact us first to see if this program is suitable for you.
Full Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*
Alternate Phone Number
We will be emailing you some important instructions as we proceed. We will also be emailing you a copy of your test results and recommendations. We also occasionally send notices, important updates, and other health-related information by email, although you can choose not to receive these at any time. We will never share your email address with anyone.*
Please enter your email address here.
Gender*
Date of Birth*

MonthDayYear
Height*
Weight*
Hair Color*
How many children do you have?*
Occupation*
How did you find out about us? (If a person, please tell us their name.)*
What are your main health concerns or conditions?*

Please list supplements you are taking, especially any you feel you want to continue (there is more room on the last page to list additional items or for more comments):

	Supplement	Dose	What symptom, if any, does this improve?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Please list any medications you are taking:

	Medication Name	What do you take this medication for?	How long have you been taking it?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

If you are using birth control, what kind are you using (type "none" if not using any)?*
Have you had any surgeries?*

YesNo
Please list the surgeries here and when they were performed:*
Please list any other health, medical or mental treatments you are currently receiving, such as physical therapy, chiropractic, acupuncture, psychiatric therapy, etc.:
Average hours of sleep per night:*
Do you take naps during the day?*

YesNo
Do you use antiperspirant deodorant?*

YesNo
What kind of exercise do you do and how often?*
Do you have difficulty taking supplements?*

YesNoSometimes
Explain the difficulty you have with supplements:*

	Severity
Joint Pain
Joint Stiffness
Back Pain
Neck Pain
Arthritis, Osteo
Arthritis, Rheumatoid
Muscle Pain
Muscle Weakness
Muscle Cramps
Bursitis
Fractures
Osteopenia
Osteoporosis
Gout
Neuritis

	Severity
Cough
Bronchitis
Asthma
Post-nasal drip
Sinus Congestion
Ear Infection
Ringing in Ears/Tinnitus
Allergies
Emphysema
Chemical Sensitivity
Infections/Viruses
Night Sweats
Non-Cancerous Tumors
Multiple Sclerosis
Parkinson's Disease

	Severity
Rapid Heart Beat
Skipped Heart Beats
Heart Palpitations
Poor Circulation
Vertigo/Dizziness
Dizzy upon standing
Low Blood Pressure
High Blood Pressure
Angina
Arteriosclerosis
High Cholesterol
High Triglycerides

	Severity
Sugar Reactions
Irritable before meals
Can't Skip Meals
Hypoglycemia
Sweet Cravings
Crave Starches
Fat Cravings
Other Food Cravings
Food Allergies
Excessive Hunger
Loss of Appetite
Diabetes, Type I
Diabetes, Type II

	Severity
Acne
Rash
Eczema
Fungal Infections
Candida
Psoriasis
Hives
Hair Loss
Slow Wound Healing
Gum Disease
Tooth Decay
Excessive Plaque on Teeth
Canker Sores
Blurred Vision
Cataracts
Glaucoma

	Severity
Constipation
Diarrhea
Intestinal Gas
Bloating
Heartburn
Celiac Disease
Ulcer
Stomach Pain
Colitis
Gall Stones
Hemorrhoids
Cirrhosis
Diverticulitis

	Severity
Fatigue
Hypothyroidism
Low Body Temperature
Cold in Winter/Dry Skin
Tend to Gain Weight
Tend to Lose Weight
Hyperthyroidism/Graves

	Severity
Bladder Infections
Kidney Infections
Trouble Urinating
Frequent Urination
Painful Urination
Kidney Stones
Water Retention

	Severity
Sinus Headaches
Tension Headaches
Migraine Headaches
Anemia
Easy Bruising
Trouble falling asleep
Trouble staying asleep

	Severity
Anger
Anxiety
Brain Fog
Confusion
Depression
Irritability
Mind Races
Mood Swings
Panic Attacks
Poor Memory
Attention Deficit
Hyperactivity

	Severity
Anorexia
Autism
Bipolar Disorder
Delayed Development
Dyslexia
Learning Disability
Mental Retardation
Schizophrenia
Seizures

	How Many?
Scars from surgeries/injuries?
Body Piercings?
Silver/Amalgam Dental Fillings?
Root Canals?
History of Heart Attacks?

	Select
Drug Addiction?
Alcoholism?
Smoking?
Cancer?

	Severity
Prostate Problems
Impotence
Infertility

	Select
No Menstruation
Hysterectomy
Abnormal Pap Smear
Menopause
Miscarriage
Currently Pregnant
Lactating Mother

	Severity
Premenstrual Syndrome
Cramps
Heavy Periods
Light/Irregular Periods
Ovarian Cysts
Fibroid Tumors
Fibrocystic Breasts
Breast Tumors
Yeast Infections
Hot Flashes
Infertility

Thank you for providing us your information. We have only one step left. Please read the following disclosure and sign your name using your mouse at the bottom. Then Submit, and we are done!
Consent and Disclosure Form

Please read the following and provide your name and signature below as appropriate:

1. Nikki Moses and Kristina Law are not licensed physicians.

2. The treatment being provided by them and Moses Nutrition, Inc. is alternative or complementary to healing arts services licensed by the state of California.

3. The services to be provided are not licensed by the state.

4. The services provided may involve:

     A. Nutritional balancing based on a hair mineral analysis (a lab-based screening test performed on body hair which shows amounts of 20 different minerals in the hair),

     B. various forms of muscle testing, including Nutrition Response Testing, and

     C. possibly other non-invasive forms of testing and stress-reduction techniques.

     D. Dietary supplements may be recommended as well as diet suggestions, detoxification procedures and lifestyle recommendations.

5. All testing, techniques and supplements are recommended/provided for the purpose of reducing stress and balancing body chemistry. The theory is that by identifying possible areas of stress and nutritional deficiency through hair mineral analysis and/or other testing mentioned above, one can then provide needed nutrients to reduce stress and balance the body chemistry. None of the services or products recommended or provided by Moses Nutrition, Inc. or Nikki Moses or Kristina Law is intended as diagnosis, prevention, treatment or prescription for any condition or disease.

6. Nikki Moses and Kristina Law have diplomas in Nutritional Balancing Science as provided by Westbrook University of Wierton, West Virginia, and taught by Dr. Lawrence Wilson of Prescott, Arizona. Nikki Moses and Kristina Law are also trained in various other techniques such as Nutrition Response Testing and Morphogenic Field Technique as provided by those various independent training entities. Nikki Moses and Kristina Law work as nutritional consultants only.

By signing below, I acknowledge that I have read and understood the information above, and I request that Nikki Moses and Kristina Law (Moses Nutrition, Inc.) perform the above services to set up a program for the purpose of enhancing my health or that of a minor under my care. I authorize Nikki Moses, Kristina Law and Moses Nutrition, Inc. to forward the hair sample (if given) and personal information to Analytical Research Labs of Phoenix, Arizona for a hair mineral analysis and to share this personal information, analysis and/or other testing results with any other health practitioner deemed necessary by Nikki or Kristina solely for the purpose of designing a nutritional program (this is rare but can occur, especially if requested by the client).
Type your name here:
Date:*

MonthDayYear
Client Signature (use your mouse to sign):*

Clear
Thank you! Be sure to click "Submit Form" below. Have a happy and healthy day!
Should be Empty:

	Never	Less than 1 time/month	1-3 times/month	1-2 times/week	3+ times/week
Do you eat dairy?
Do you eat eggs?
Do you eat beef?
Do you eat fish?

	Yes	No
Do you eat mostly organic food?
Do you avoid gluten grains?
Do you eat often at restaurants?

New Client Form – for Adults, 18 Years and over

Tell us about your diet (details are important so be specific):

Tell us about your symptoms:

Please look through all of the symptoms below and rate any you have experienced within the last few months, including symptoms you have had for a long time. Leave the symptom blank if that symptom does not apply to you. There is room at the end of this section for additional comments and symptoms.

When we receive your hair sample in the mail, we will email you to let you know it arrived safely.

Thank you so much! We look forward to getting you started! This form does not book your appointments for you, so be sure to schedule any hair-sampling or consultation appointments using our online scheduling at www.MosesNutrition.com, or you may call our office to schedule.

Great! If you do not receive the email with the copy of your form, be sure to check your junk mail. If you think of new information you would like to share with us, you can send it to us by replying to that email or by emailing us via our website.

Great! If you think of new information you would like to share with us, you may email us via our website.

Thank you for providing us your information. We have only one step left. Please read the following disclosure and sign your name using your mouse at the bottom. Then Submit, and we are done!

Thank you! Be sure to click "Submit Form" below. Have a happy and healthy day!