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† HEALER'S SURVEY ∆

 

 

 

 

 

Please If You Are A Customer Of Mine

I Would Love If You Would Help Me Out By

Filling Out My Healers Survey...

You Being The Healy This Is Very Important,

Because Most Likely The Only

Reason You Trusted Me Truly In The First Place,

Is Because You Hear The Word Of Mouth

About How I Am Curing People Left And Right,

So Now I Am Establishing Something Even More

Additional With The PERFECTIONAL PRACTICE©

 

As I Am Going To Need Your Complete And Sincere Cooperation With me Now...

I Need You To Answer These So We Can

HELP SAVE THE WORLD,

As I Promised Before, TOGETHER.

We Can Do This, I Just Need Your Help Now,

Can You Help Me?

It Only Will Take Ten Minutes Top..

Please Just Answer And Put Your Name-

Email (If You Want) - And Age- (If You Want)

And What Problems You Had Before

And If You Still Have Them

Or If You Don't Notice Them

As Much Or If They Are COMPLETELY GONE....

And Here Lets Jump Into The Rest, Lets Do This, Alright?

_________________________________________ 
 
∆∆∆ HEALER'S SURVEY  †††
 NEW INSTITUTION OF NUTRITION  
*PICK ONE OR AS MANY THAT APPLY:
_________________________________________
 

 
 
1.)  •Energy level:
  10=Excellent, 1=Poor
 
  2.)  Head:
•I am pale
•I have a red flushed complexion
•My chest has a red flush to it
•8I get headaches
 
  3.)  The climate seems to make my condition worse when:
 
•It's hot
•It's damp
•It's cold  
•Climate changes do not affect me
•It's dry
 
 
4.) Sleep:
•Trouble falling asleep
•Trouble staying asleep
•I wake in the middle of the night
•I have vivid dreams
•I sleep more than 10 hours a day   
• I take sleep medications
•I feel anxiety when I try to sleep
 
  5.) Subjective Body Temperature:
 
•I have night sweats
•I feel warm most of the day
•I use multiple blankets when I sleep
•I prefer to wear sweaters
•Heat makes me feel tired
•My hands and feet are always colder than the rest of my body
•I feel chilled most of the time
 
  6.) Appetite/Thirst:
 
•I prefer chilled beverages  
•I am hungry all the time
•I have bleeding gums
•I have bad breath
•I am overweight
•I am underweight
•I prefer warm beverages
•I don't have much of an appetite  
 
  7.) Digestion:
Loose Stools:
 
•After eating
•When I wake up
•Foul smelling
•Undigested food particles
•Multiple movements throughout the day
•Constipation
•Bloating Belching
•Flatulence
•Vomiting
•Nausea
•Pain in the diaphragm area
•Stomach pain  
•Acid reflux
 
 
 
  8.) Elimination:
•Frequent daytime urination
•Frequent nighttime urination
•Clear profuse urination
•Dark/ pungent smelling urination  
•Known Prostate problems
 
  9.) Skin & Nails:
•Dry/flaky skin
•Oily skin
•Itchy skin
•Acne
•Rash
•Dry hair
•Greasy hair
•Thinning hair
•Balding
•Dry/flaky finger nails  
•Fungus on toenails  
•Lipomas
•Varicose veins
•Liver spots
 
  10.) Eyes:
•Cataracts
•Dry eyes
•Glacoma
•Red/blood shot eyes
•Watery eyes/discharge  
•Itchy red eyes
•Loosing eye sight
•Eyesight loss
 
  11.) Ears:
•Deaf
•Chronic ear infections with smell
•Sensitive to noise  
•Chronic ear infections without smell
•Hearing loss
 
  12.) Lungs:
•Asthma
•Worse with inhalation  
•Worse with exhale
 
Chronic cough
•Wet
•Dry
•Allergy related  
•Flu related
•I have lots of phlegm  
•I smoke
 
  13.) Nose:
•Nasal congestion without mucus  
•Nasal congestion with mucus
•Clear mucus
•Green mucus
•Yellow mucus
•Dry nose
•Itchy nose
•Sneezing
•Nasal congestion that occurs seasonally
 
  14.) What season worsens your condition?:
 
 Winter   Spring   Summer   Fall   All seasons
 
Comment:
 
 15.) Emotions:
 
•Aggressive
•Lots of anger/short tempered
•Restless
•Withdrawn: prefer to be alone
•Anxious
•Depressed
•Cry frequently  
•I take anti-depressant medications
 
  16.) Pain: Location
•Head
•Neck
•Shoulders
•Upper back
•Lower back  
•Hips
•Knees 
•Elbows
•Wrists
•Fingers
•Toes
 
•Bursitis?
Tendons problems (tell the location below)
 
•Gout? Doctor has said you have arthritis?
•Doctor has said you have R.A.?
 
The type of pain can be described as:
•Dull
•Aching
•Sharp/stabbing
•Worse with movement
•Better with movement
 
•I have swelling around the joints  
•I have redness around the joints
•Cold makes it worse
•Heat makes it worse
•Damp weather makes it worse
 
•Do you have weakness of the lower back?  
•Do you have weakness of the knees?
 
•When did the pain start?
•Does anything make it better?
•Does anything make it worse?
•Comment:
 
 
 
Client Name: Age: Sex:
Severity:   (10=Very Severe) Weight:
What is your main compliant today?
How long has it been a problem?
 
List all medications and supplements you are taking:
List all herbs that you are taking?
What medical diagnoses have you received?
Review of systems:
Do you have high blood pressure?
Do you have any problems with your Heart?
Do you have problems with your Liver?
Do you have problems with your Kidneys?
Do you have neurological problems?
 
When Did You START Following Mr.Plott's Protocol?
 
When Was The Date You Noticed A Change?
-Was It Better Or Worse?
 
Did Mr.Plott's Protocol Alleviate Your Issues Or Problems Moderately, Completely, Or Not At All?
 
What Was The Protocol Mr.Plott Assigned To You?
 
SIGNATURE: 
 
 
~E.G.Plott~
Perfectiona Practice©
 
  PLEASE INCLUDE THE FOLLOWING AND SEND TO ericplott@hotmail.com Or mail to us. You can Mr. Plott On Facebook Here: https://www.facebook.com/blaze573 
 
 
Client First Name:
 
Last Name:
 
Email Address:
 
Retype Email Address:
 
Phone #:
  
Cell/Nightime Tel #:
 
Best Time to Call:
 
Prefer Phone call or Email:
By Phone By Email
Have you ever worked with herbs before?
 
Please tell us what questions or concerns you may have so that we may help you purchase one of our formulas: