Time of birth
Place of birth
What are your main health concerns or conditions?
Please list any medications or food supplements you are currently taking
Please note any pain or tension areas and indicate level of discomfort on scale of 1-10, noting which side is painful or tense of the same muscle
Please list any recent medical test results you have, such as blood tests
Past surgeries and dates
Please list illness in your family such as heart disease, cancer, TB, diabetes, arthritis etc.
How often and what kind of exercise do you do?
About how many hours of sleep do you get per day?
Honest Example of your Diet?
What are examples of typical breakfasts for you? Beverages?
What are typical lunches for you? Beverages?
What are typical dinners for you? Beverages?
Fatigue & exhaustion
Mind is in a fog
Super Sensitive, weepy
Cold hands, and/or feet
Feeling of loss of control
Despair, suicidal feelings, hopelessness
Arthritis, calcium spurs
Racing heart, pounding heart
Adverse reaction to vitamins & minerals
Problems with concentration and memory
Short attention span, "spaciness"
Eating disorders: anorexia, bulimia, overeating
Panic attacks, high anxiety, free floating anxiety
Yeast infections (candida)
Aching muscles or muscle cramps
Mind races -- insomnia, interrupted sleep
Low blood pressure
Hypothyroid (slow thyroid)
None of the Above
Consent, Disclosure and Liability
I acknowledge that John Bumpus has advised me that Nutritional Balancing, Integrative Mineral Balancing, Hair Tissue Mineral Analysis and Health Coaching are not medical advice and is in no way intended to replace my regular medical attention. I understand that John Bumpus has a diploma in Nutritional Balancing Science and will work with me using the techniques learned through his education so that I can learn to manage my stress and pain, so that I can attain my full potential and optimal health to make natural wellness possible. I request that John Bumpus, perform a Hair Tissue Mineral Analysis and set up an Integrative Mineral Balancing program for the purpose of reducing stress, enhancing health and improving wellbeing. I understand that Integrative Mineral Balancing, Nutritional Balancing, Hair Tissue Mineral Analysis, and Health Coaching is not intended as a diagnosis, treatment, or prescription and is not a substitute for regular medical care. I understand that Integrative Mineral Balancing, Nutritional Balancing and Health Coaching is a means to reduce stress and balance body chemistry. Integrative Mineral Balancing, Nutritional Balancing, Health Coaching or Hair Tissue Mineral Analysis is not intended as diagnosis, treatment or prescription for any condition or disease. I understand that Sauna Therapy or Infrared Lamp Therapy is a way of enhancing circulation, decongesting internal organs, and increasing the activity of the skin through the application of heat to the body. It is not a diagnosis, treatment, prescription or cure for any health condition, nor is it intended to replace regular health care. I agree to release John Bumpus, a Hair Tissue Mineral Analysis Practitioner, Certified Nutritionist, Health Coach, and Certified Herbalist, and their agents, representatives, successors and assigns from all manner of actions, causes of action, debts and demands I ever had, and now have or which my heirs, executors, administrators, assigns, or any of them, may have in the future that may arise as a result of any illnesses, injuries or death, and damages that I may sustain while participating in Integrative Mineral Balancing, Nutritional Balancing, coaching or herbal therapies. I agree to indemnify John Bumpus, against any and all liability for losses and expenses of any kind or nature that may incur as a result of my actions while participating in this program. I agree, that I have read and understood the above.