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Your Details

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Secondary Contact Details

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Personal Information

Date of Birth

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Health Information

Select a unit of measurement

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Height (cm) *

Weight (kg) *

BMI *

You fall into the Underweight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Healthy weight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Overweight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Obese category. Please note that these descriptions are a rough guide and are not intended to be definitive.

If you are 6 ft 5 in, enter 6 in the Height (ft) column and 5 in the Height (in) column.

Height (ft) *

Height (inches) *

Weight (lbs) *

BMI *

You fall into the Underweight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Healthy weight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Overweight category. Please note that these descriptions are a rough guide and are not intended to be definitive.

You fall into the Obese category. Please note that these descriptions are a rough guide and are not intended to be definitive.

Type of cancer, size of tumour(s), dates of diagnoses and method(s) of detection *

Allopathic medical treatments received *

Click here to see more examples of allopathic medical treatments. If not applicable, write N/A

Naturopathic medical treatments received *

Click here to see more examples of allopathic medical treatments. If not applicable, write N/A

What symptoms of illness do you have nowadays? *

If not applicable, write N/A

What pain and discomfort, are you experiencing these days? *

If not applicable, write N/A

Physical factors that may have triggered cancer *

If not applicable, write N/A

Emotional factors that may have triggered cancer *

If not applicable, write N/A

Environmental factors that may have triggered cancer *

If not applicable, write N/A

Do you smoke cigarettes? *

Weekly alcohol consumption *

Recreational drug consumption *

Pharmaceutical medications currently taken *

Which covid vaccine(s), if any, have you taken? *

Naturopathic supplements currently taken *

Types and frequency of physical exercise *

Do you use non-organic chemical forms of these products?

shampoo/conditioner
deodorant
hair dye
toothpaste
household cleaning products
washing detergents
cosmetics

Do you have any dental amalgams? *

Do you use a microwave oven? *

Do you use Teflon pots and pans? *

How much water do you drink each day?

On average, how many bowel movements do you have each day?

What have you typically been eating for breakfast? *

What have you typically been eating for lunch? *

What have you typically been eating for dinner? *

What snacks do you typically eat? *

What drinks do you typically consume? *

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Your Beliefs

What is your belief that you can achieve a complete recovery using modern allopathic medicine?

Your Belief: 50%

What is your belief that you can achieve a complete recovery using naturopathic medicine?

Your Belief: 50%

What is the level of support from family and friends you are receiving for pursuing a holistic healing path?

Your Belief: 50%

What is your average energy level?

50%

What is your level of anxiety regarding your health?

50%

Have you read “The Healing Power of Cancer” by Rob Prior? *

What were your biggest lessons from reading this book? *

To what extent have you followed Rob’s protocols? *

Have you read “Say Hello To Happiness (The Healing Mindset)” by Michael Adamedes and Rob Prior? *

What were your biggest lessons from reading this book? *

How has it helped you? *

Do you have any further comments or questions? *

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