1. Full Name*

2. Email Address*

3. Mobile*

4. WhatsApp Number*

5. Country*

6. Age*

7. How did you hear about us/our program?* (Check ALL that Apply)

8. How do you feel about incorporating prayer & scripture into your healing program? *

Desire it because of my faith Not opposed to it Uncomfortable

9. What best describes your spirituality? *

10. Which best describes your issue?* (Check ALL that Apply and Specify diagnosis/any pertinent details below)

11. If you have Fibroids, how many and what sizes are they according to your most recent test and what date did that take place? *

As much as possible, please provide exact details on the number, size and location if known.

12. If you have Gut Issues, which of the following do you experience? * (Check ALL that Apply and detail how you experience it)

13. Medical overview of your story/case *

Please include dates to provide a timeline where possible–also identifying any surgeries and/or advanced reproductive technology treatments (such as IUI or IVF) you have undergone.

14. What are your most severe symptoms? *

15. What is your current emotional condition? * (Check ALL that Apply)

Fearful
Sad
Indifferent/Numb
Content
Happy

16. What is your current spiritual condition? * (Check ALL that Apply)

Hopeless
Indifferent
Hopeful

17. Do you exercise regularly and if so how often and what kind of exercise? *

18. What is your occupation? Do you have a sedentary or very active lifestyle? Does your work require much physical activity? *

19. What kind of support system do you have at home to encourage and help you on this journey? Strong, Moderate, Weak or Non-Existent? Please describe. *

20. What best describes your diet? *

Traditional diet including red meat
Traditional diet primarily poultry and fish
Pescatarian: primarily fish
Vegetarian
Vegan
 Fibroid Elimination Diet

21. What Allergies do you have, if any? Please list ALL and severity of response. *

22. Do you have any other medical issues that we should be aware of? * (Check ALL that Apply)

23. What, if any, medications have you taken in the past (including any form of Birth Control) and how long were you on it? *

24. What, if any, medications are you currently taking and what do they treat? *

25. What best describes your budget for this treatment? *

$350 to $500 $500 to $750 $750 to $1,000 $1,500 to $2,500 $2,500 to $3,500 $3,500 to $5,000

26. What time zone are you in? *

Eastern Central Mountain Pacific