Client Forms

Client Re-Test Form

Please complete all sections below for your re-test. Fields marked with an asterisk (*) are required.

Important: Diane Leto is certified in Development and Nutritional Balancing Science and does not hold a state-licensed medical degree, nor does she diagnose, prescribe, treat, or cure any disease or health condition. Development is not a substitute for regular medical care. Please consult a licensed medical provider for diagnosis and treatment of any medical concerns.
Note: All information is kept confidential by Provider. However, forms are submitted over the internet and while email security procedures are in place, there is a possibility that the form may be intercepted by third parties. If there is a concern, you can print and mail the form directly to us. Contact us for the mailing address.

Personal Information

First Name

Last Name

Street Address

City

State

ZIP Code

Email Address

Phone Number

Gender

Age

Hair Color

Height

Weight

Occupation

Program Modules

On a scale of 0–5, how closely have you been following your program?
0 = Not at all · 5 = Perfectly

Diet

Supplements

Water

Lifestyle

Rest

Sauna / Heat Lamp

Spinal Twist

Foot Rubs

Coffee Enemas

Roy Meditation

Skin Brushing

Lifestyle & Wellness

Diet: Describe examples of typical foods eaten at each meal

Meal	Food	Beverage
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Evening Snack

Exercise Frequency

Type of Exercise

Average Hours of Sleep Per Night

Program Questions

Please take a moment to answer the questions below. Your responses help us tailor your updated program.

1. Describe changes you have noticed in your symptoms or condition over the past several months.

2. Do you have questions regarding your supplements, diet program, sauna therapy, or coffee enemas?

3. Do you have questions in regard to any emotional aspects, meditation, or lifestyle challenges?

4. Are there other concerns you would like us to address when updating your program?

Re-Test Consent, Disclosure & Disclaimer

Please read each statement carefully and check the box to indicate your understanding and agreement.

I understand that Nutritional Balancing/Development Program is not intended as diagnosis, prescription, treatment or cure for any disease or health condition, mental or physical, real or imaginary. It is also not intended as a substitute for regular medical care and that I am encouraged to seek a second opinion from a medical provider and that any nutritional balancing information offered is considered as general information only.

I understand that under no circumstances should any medication be discontinued without first consulting the prescribing medical provider. I will refrain from combining this program with other dietary, nutritional or herbal regimens as it may impair this program's effectiveness. I also confirm by signing this document that I have not been diagnosed with any form of cancer or am in remission from any form of cancer.

I understand that the Nutritional Balancing/Development Program information offered is also not intended as a substitute for regular medical care and that I am encouraged to see my medical provider for diagnosis and treatment of any medical concerns that I may have, and before implementing any diet, supplement, exercise or other lifestyle change. I also understand that Nutritional Balancing/Development Program is to be used at my own risk.

I have read, understand, and agree to all of the provisions of the above Consent, Disclosure & Disclaimer.

Print Applicant's Name (Electronic Signature)

Date

Electronic Signature

By typing your full legal name below and submitting this form, you are providing your electronic signature and confirming that all information provided is accurate and complete to the best of your knowledge.

Full Legal Name (Electronic Signature)

Date

All required fields () must be completed before submitting.

Client Re-Test Form

Personal Information

Program Modules

Lifestyle & Wellness

Program Questions

Re-Test Consent, Disclosure & Disclaimer

Symptoms

Musculoskeletal

Blood Sugar / Metabolism

Cardiovascular

Respiratory

Skin, Hair & Eyes

Mental / Emotional

Neurological / Developmental

Digestive / Other

Addictions

Thyroid / Energy

Urinary

Women Only

Men Only

Electronic Signature