Disclaimer: Nutritional mineral balancing is a means to reduce stress and is not intended as diagnosis, treatment or prescription for any condition or disease.

Name *
Name
Are you a member of NB Friends Facebook group? *
Year/Month/Day
Year, Month, Day
in lb's
In feet and inches
Street address
or Mobile
Type, Ounces, How often
Type, How often
Type, How often
What are examples of typical breakfasts for you? Beverages? Mid-morning Snacks? What are typical lunches for you? Beverages? Mid-Afternoon Snacks? What are typical dinners for you? Beverages? Evening Snacks?
Overview of Symptoms
Digestive Symptoms *
Symptoms of Gluten Intolerance *
Symptoms for 100% Gluten-free diet for the following imbalances *
Symptoms of EFA & Cholesterol Deficiencies *
Symptoms of Blood Sugar Imbalances *
Symptoms of Calcium Imbalances *
Other Symptoms and Health Concerns *
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 nutrition coaching. I agree, have read and understood the above.