Lawrence
Wilson, MD* and Associates www.drlwilson.com
928) 445-7690
Name___________________________________ Phone________________
Age ________ Sex M F
Address
__________________________________________________________________________
a) Please follow the instructions for hair sampling
carefully, and cut enough hair to balance the scale.
b) Mark your name, age and sex on the small paper hair envelope. c) Answer the questions below.
d) Circle your current symptoms on back of this sheet. e) Mail to Dr. Wilson at the address
below.
1. On a
scale of 0-5, how closely have you been following your program? 0=not at all 5=perfectly
Supplements_______ Diet_______ Sleep_______ Saunas_______ Enemas______ Meditation______
2. Describe changes you have you noticed
in your symptoms or condition over the past several months.
3. Do you have questions in regard to your
supplements, diet program, sauna therapy or coffee enemas?
4. Do
you have questions in regard to emotional aspects, meditation or lifestyle
challenges?
5.
Are there other concerns you would like us to address when updating your
healing program?
The retest fee is $150.00 US. This includes your hair analysis, a
consultation on compact disc describing your new comprehensive healing program
and brief follow up phone calls or emails. Payment can be by check, money order in US dollars, or send
credit card information, including expiration date and the 3 or 4-digit
security code. There is a $35
charge for international shipping and handling.
Mail
this sheet, the hair sample and your payment to: Dr. Larry Wilson, P.O. Box 54,
Prescott, AZ 86302-0054.
Thank you! You should
receive your program within about 3 weeks .
* Nutritional balancing is a means to reduce stress and is not intended as diagnosis, treatment or prescription for any condition or disease. Dr. Wilson has a medical degree and works as an unlicensed nutrition consultant only.
SYMPTOM SHEET
Directions: CIRCLE any conditions that presently describe you. Put a STAR next to the most important symptoms
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Joint Pain Joint Stiffness Arthritis, Osteo Arthritis, Rheumatoid Muscle Pain Muscle Weakness Muscle Cramps Bursitis Fractures Osteoporosis Gout Sweet Cravings Sugar Reactions Irritable before meals Can't Skip Meals Hypoglycemia Crave Starches Fat Cravings Other Food Cravings Food Allergies Excessive hunger No hunger Diabetes Rapid Heart Rate Skipped Heart Beats Heart Palpitations Heart Attack Poor Circulation Dizziness Low Blood Pressure High Blood Pressure Angina Arteriosclerosis High Cholesterol______ High Triglycerides____ Cough Bronchitis Asthma Post-nasal Drip Sinus Congestion Allergies Emphysema Fatigue Hypothyroidism Low Body Temperature Cold in Winter/Dry Skin Tend to Gain Weight Hyperthyroidism
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Acne Eczema Fungal Infections/Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Meniere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease Get Infections Easily Epstein-Barr Virus Tumors/Cancer Multiple Sclerosis Parkinson's Disease Scleroderma Anger Anxiety Bipolar Disorder Brain Fog Confusion Depression Irritability Mind Races Mood Swings Obscessive/Compulsive Panic Attacks Poor Memory Schizophrenia Trouble Sleeping Autism Attention Deficit Hyperkinesis Dyslexia Seizures Learning Disability Mental Retardation Delayed Development Bladder Infections Kidney Infections Trouble Urinating Frequent Urination Painful Urination Kidney Stones Water Retention Painful Urination Kidney Stones Water Retention
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Sinus Headaches Tension Headaches Migraine Headaches Neuritis Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tend to Gain Weight Tend to Lose Weight Anemia Easy Bruising Drug Addiction Alcoholism Smoking WOMEN: Premenstrual Syndrome Water Retention Cramps No Menstruation Heavy periods Light Periods Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocystic Breasts Breast Tumors Yeast Infections Hot Flashes MEN: Prostate Problems Impotence Infertility Other Symptoms or Comments:
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