7 Essentials for Healing and Preventing Breast Cancer

7 Essentials for Healing and Preventing Breast Cancer

Coaching Questionnaire

Essential #1: Let Food Be Your Medicine

Describe your typical breakfast, lunch , dinner:

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How often do you eat out?

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Do you eat Fast food, junk food? Describe what you eat and how often.

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What kind of meat do you eat? Chicken, beef, pork, turkey, fish. How many times per week?

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Is the meat hormone or antibiotic free?

______

Do you eat food that has artificial ingredients, flavorings and preservatives? What and how often?

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Are you willing to change your eating habits?

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Do you eat when you are stressed or tired? Late at night?

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How much water do you drink on a daily basis?

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What kind of water do you drink? Bottled, tap, spring, purified, filtered, distilled?

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Do you crave certain foods? Salt? Sugar? Carbs? Proteins?

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What kind of salt do you use? Do you use it with every meal?

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Do you drink coffee or black tea? How many cups per day? How do you drink it? (dairy, sweetener)

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Do you follow any particular diet or eating style?

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Do you avoid certain foods like sugar or dairy? If so, what are the avoids for you?

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Do you drink hard liquor, wine or beer? How much and how often?

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Do you juice? What kind and how often?

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What kind of juicer do you use?

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Do you drink Green drinks or smoothies? What kind and how often?

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What type of blender do you use?

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What is the percentage of cooked versus raw food in a typical day?

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Do you feel you digest your food well? Or do you have any gas, bloating, burping, reflux?

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Do you take any probiotics or digestive enzymes?

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What is your Blood Type?

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Essential # 2: Reduce Your Toxic Exposure

Have you ever worked in a toxic environment where you were exposed to chemicals and fumes?

______

Were you ever exposed to environmental chemicals in your childhood years?

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What are the types of household cleaners that you use?

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How often do you use them?

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Do you wear gloves when cleaning?

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Do you use air sprays like Febreeze or artificially scented candles?

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What kind of detergents do you use for clothes and dishwasher?

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What kind of shampoo, conditioner and body soap do you use?

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What kind of toothpaste do you use? Mouthwash?

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Do you wear make up? What brand?

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Do you use a deodorant? Anti-perspirant? What kind?

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Do you use sunscreens? What kind and what strength?

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Do you have your home sprayed with insecticides?

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Do you use weed killers and artificial lawn and plant chemicals?

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Are you willing to change the type of products you use on a daily basis?

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Have you ever had a bacterial infection? What kind and when? How was it treated?

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Have you ever had a viral infection? What kind and when? How was it treated?

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Have you ever had a fungal infection? What kind and when? How was it treated?

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Do you have issues with nail fungus on your fingers or toe nails? How long? How have you treated it?

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Do you have a white coating on your tongue?

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Do you have white spots or little red bumps on your skin?

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Have you ever had parasites? What kind and when? How was it treated?

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What kind of cookware do you use? Aluminum pots? Stainless steel, etc.

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Do you use a microwave oven? How often?

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When you use a microwave oven, do you use plastic or saran wrap like cover?

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Do you use aluminum foil to bake your foods?

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Do you store your food in plastic containers?

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Do you take any pharmaceutical drugs or prescribed medications? Please describe.

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Do you have WIFI in your home?

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How many hours to you spend on a cell phone and in front of your computer per day?

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Do you feel you are sensitive to electro-pollution or EMF’s?

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Do you have Breast Implants? What type and for how long?

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Have you had any surgeries in the last 5 years? What kind?

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Are you familiar with Coffee enemas? If you implement them, how often?

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Essential # 3: Balance Your Energy

Did you know that your body is electrical, has an energy flow and a bio-field that surrounds it?

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Are you under Chiropractic care? Have you ever seen a Chiropractor?

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Have you ever done Yoga? Chi-gong or other eastern healing arts?

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Have you ever done Acupuncture? When and for what reason?

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Do you sleep well at night? What time do you go to bed? Do you wake up frequently?

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Do you meditate? How often and what type?

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Do you exercise? How often and what type?

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How old were you when you had your first cycle?

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Do you still have a cycle? Date of last period?

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Menopause or hysterectomy? How many years ago?

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Do you feel your hormones are balanced? Describe your symptoms.

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Have you ever been on any kind of Birth Control Pill? When? What type and for how long?

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Have you ever had a saliva test for your hormones? Please provide copies.

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Have you ever done a 24 hour urine Iodine Loading test? Please provide results.

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Have you had your Vitamin D3 levels tested this year? Please provide results.

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Have you had any recent blood work done? Please provide copies of the latest results.

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Do you know if your pH is acidic or alkaline?

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Are you willing to learn about ways to balance your physical energy and life force in your body?

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Essential #4: Heal the Emotional Wounds

Do you consider yourself a happy person?

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Are there things that you are passionate about that keep you motivated about your future.

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Do believe you have problems with your self-esteem? If so, please explain.

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Do you feel stressed out? If so, why and how often?

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Are there any major traumas that have happened in the last 18 months to 2 years? (divorce, death of a loved one, financial problems, etc)

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How do you react to stress? (outbursts, cry, get quiet, exercise, sleep, etc)

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Are there any childhood traumas that you feel are still unresolved?

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Are there any childhood traumas that you feel are resolved and forgiven?

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Are you open and willing to do some emotional healing?

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Is there anything that you would like to share about your heart and emotions?

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How do you feel about your current health challenge? Do you believe your body can heal and recover?

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Have you ever heard of EFT, Energy Psychology or other emotional healing arts?

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Do you feel you are connected to a Higher Power?

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Do you have a support system of friends and family or do you feel like the “lone ranger” on this journey?

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What frustrates you the most about having Breast Cancer?

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What do you fear the most about having Breast Cancer?

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What type of information would be most helpful for you on this journey?

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How can I best support you? What do you need or want from me as a support and/or coach?

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Essential # 5: Embrace Biological Dentistry

How many silver metal fillings do you have?
Upper Right______
Upper Left______
Lower Right______
Lower Left______

How many crowns or caps?

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Location of crowns and caps

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How many root canals?______

Location of root canals?

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Do you have any dental metal implants?

______

Do you have any Bridges?

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How often do you brush your teeth?

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How often do you floss your teeth?

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How often do you visit the dentist?

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Do you get Fluoride treatments?

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Have you ever heard of the connection with disease and root canals and metal fillings?

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Are you open to exploring the dental connection?

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Essential # 6: Repair with Therapeutic Plants

Have you ever used any herbal supplements or homeopathic remedies? What kind and for what purpose?

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Are you presently taking any herbal supplements or vitamins? Please describe

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Have you followed any type of anti-cancer protocol and for how long? (Budwig, Gerson, etc)

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Have you worked with a Naturopath or Integrated oncologist? If so, what type of program did they recommend?

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Do you drink herbal teas? What kind?

______

Have you ever tested your Iodine levels with a 24 hour Iodine loading test?

______

Have you had a Vitamin D3 blood test to check your levels? If so, what were your levels?

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Do you supplement with Vitamin D3? If so, how much?

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Are you drinking any anti-cancer teas? Please describe.

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Are you taking any Probiotics? What kind? How often?

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Essential # 7: Adopt Very Early Detection with Thermography

and Specific Blood Tests

Do you do yearly mammograms? For how many years?

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Have you had any diagnostic tests to confirm your diagnosis?

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Have you ever had any biopsies, ultrasounds, MRI’s or Pet Scans? If so, please provide the results.

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Have you done any blood work in the last 2 years? If so, please provide results.

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Have you ever had any reconstructive surgery to the breasts? Any implants? What kind and when?

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Have you ever had a Breast Thermogram? If so, when? Please include copies of your reports.

______

Please provide your age ______

Date of Birth ______(This is for requisitions for any lab work, should you decide to order some tests)

Height ______Weight ______

If you can also send a photograph of your beautiful self, I would appreciate it. I like to see the face and not just hear the voice. Even if we Skype, I like to keep a photograph of you in your file. Thank you.

Waiver and Disclaimer:

I understand that the 7 Essentials Coaching Program is for informational purposes only and not medical advice. It is not meant or designed to make any medical claim about treating or curing cancer or any type of disease.

The 7 Essentials Coaching Program is not intended as a substitute for the diagnosis, treatment or advice of a qualified, licensed medical professional.

The 7 Essentials Coaching Program is not medical advice, nor does it replace the recommendations from your primary care physician. It is highly encouraged that you do not disregard the medical advice that you have been given concerning treatments and medications from your primary care physician.

Any statements or information concerning cancer or any disease have not been approved by the FDA, AMA or any federal or state agency. This is general information and is NOT intended, nor should it be used as a substitute for medical advice.

Consult your primary care physician for any issues concerning your health.

By signing this form I am assuming full responsibility for my health and decision concerning my health and well-being. I understand that the information received through Breast Cancer Conqueror, LLC is for informational purposes only and that I take full responsibility for implementing any protocols or changes in my life style.

I have read and understand the Waiver and Disclaimer.

Signed: ______Date: ______

I certify that my Electronic signature is as valid as a hand signed signature.

Terms and Conditions

By purchasing The 7 Essentials Coaching program, I understand and agree that the coaching program consists of not only one on one time consultations with Dr. V, but also includes time that may be spent on the following:

Research for a particular issue

Consultations with other doctors

Communication and replying to emails.

Time logs are kept and may be requested at any time.

I have read and understand the Terms and Conditions

Signed: ______Date: ______

I certify that my Electronic signature is as valid as a hand signed signature.

All rights reserved. No part of this questionnaire may be reproduced or transmitted in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the copyright holder, except by a reviewer who may quote brief passages in a review. © 2014 Breast Cancer Conqueror, LLC

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