Remote Energy Testing
RET
Book Session
Kyle
Contact
Health Form
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Indicates required field
Name
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First
Last
Email
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Phone Number (include country code if outside USA)
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Communication Preference
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Zoom
Facetime
Signal
Telegram
Phone Call
Video or Audio Only
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Video
Audio Only
What are your Priority Issues? List up to 10 issues
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Age
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Gender
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Female
Male
Other
List 5 to 15 top foods you eat
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Fruits
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Vegetables
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Grains
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Seafood (only animals, list plants in supplements not here)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Meat (non-seafood)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Dairy
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Oils (coconut, ghee, olive, other)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Legumes (beans, lentils, peas, etc)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Nuts
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Seeds
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Herbs and Spices
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Fermented Foods (sauerkraut, kimchi, yogurt, kefir, and miso, etc)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Sweets and Snacks (desserts, candies, and processed snack foods)
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Known Food Sensitivities
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Gluten
Fructose
Histamines
Soy
Eggs
Caffeine
Sulfites (wine, dried fruits, etc)
Food Additives (MSG, artificial colors, and preservatives)
Nightshades (tomatoes, potatoes, peppers, and eggplants, etc)
Shellfish
Chocolate
Onions or Garlic
Citrus Fruits
Nuts (any)
Seeds (any)
Alcohol
Meat
Legumes
Casein or Lactose
Spices (any)
Yeast
Corn
Oxalates
Phytic Acid
Other
None
Other Known Food Sensitivities (leave blank if none)
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Fluid Intake Daily
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Under 1 Liter
1 - 2 Liters
2 - 3 Liters
3 + Liters
Coffee
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Over 2 cups a day
1 to 2 cups a day
Under 1 cup a day
Rare
Never
Tea
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
List types of tea you consume (leave blank if none)
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Alcohol
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Daily
Multiple times per week
Once or twice per week
Less than once per week
Never
Type/s of alcohol (leave blank if none)
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Smoking
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Cigarettes / Cigars
Cannabis
Vape
Other
Never
How many bowel movements on average / day?
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less than 1
1 - 2
2 - 3
over 3
Currently Working
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Yes - outside home
Yes - work from home
No
Stay at home parent / caregiver
Disability
Living Situation
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By self
With family
With friends
With significant relationship/s
Other
Any Pets in Home
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Yes
No
Type of pet, how many (if any)
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State...Country if other than USA
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Housing Type
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House - Rural
House - Suburban
House - Urban
Apartment - Rural
Apartment - Suburban
Aparment - Urban
Current Stress Levels
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High
Moderate
Low
Significant Dental History
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Yes a lot
A few cavities only
Never any dental issues
Physical Trauma History
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Serious injury history
Some broken bones and / or 10 plus stiches
Broken bone, few stitches
No broken bones, no stiches
Physical Trauma History, include locations on body
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Any significant physical trauma history.
Sleep Quality
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Terrible
Poor
Okay
Good
Great
Do You Remember Your Dreams?
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Yes, often
Sometimes
Rarely
Never
I don't think I dream
How is Your Emotional Stability?
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Great
Good
Ok
Could be better
Bad
Emotional Trauma History
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A lot
Moderate amount
Not much
Significant Emotional Trauma History
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Any significant emotional trauma you wish to share.
Exercise Levels
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None / very little
Moderate amount
Very active - weights and cardio multiple times a week
Screen Consumption
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A lot - over 7 hours a day
Moderate - 3 to 7 hours a day
Not much - under 3 hours
Almost none - I'm Amish :)
Do Any of Following
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Don't use a shower filter
Don't use a drinking water filter
Drink tap water
Don't use hypoallergenic detergent
Don't use hypoallergenic dish soap
Use non-organic makeup
Don't use air filter
Use fluoridated toothpaste
Not turn off room electric at night
Sleep with cell phone in same room
Leave wifi router on at night
Have head of bed against wall
How is Your Mental Health?
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Great
Good
Ok
Could be better
Bad
Do You Have a Hard Time Concentrating Long?
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Yes
Usually
Sometimes
Rarely
Never
Belief in Higher Power
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Yes
Not sure
No
Rather not say
Do You Belive The Soul Continues After Physical Death?
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Yes
Not sure
No
Rather not say
Current Supplements / Medications - please include brand names and amount for supplements if you want them tested for strength and sensitivity
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Please list any current supplements / medications you're taking. Ideally include the brand, dose, and frequency.
Any Additional Comments Before Testing
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Testing will be done right before and during your Session and you can ask any questions then.
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RET
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Kyle
Contact
Health Form