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Natural Alternative Cancer Clinic Featuring The Budwig Diet

“A calm heart gives life to the body" - Pr 14:30 NWT

Dr. Johanna
Budwig

Patient Sign Up Form

Thanks for your interest in the Budwig Center. In order for us to best assist you with your enquiry, please submit the form below. We look forward to hearing from you.

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Personal Information


FemaleMalePrefer not to say

Your Diet

Which of the following do you consume on a weekly basis?

Store-Bought Pastries (white refined sugar)Soft/Fizzy Drinks/Soda (white refined sugar)Boxed Cereals (white refined sugar)Fructose (white refined sugar)Chocolate Bars (white refined sugar)Corn Syrup (white refined sugar)Aspartame (artificial sweeteners)Equal® (artificial sweeteners)NutraSweet® (artificial sweeteners)Nutrinova® (artificial sweeteners)Saccharin (artificial sweeteners)Splenda® (artificial sweeteners)Twinsweet ® (artificial sweeteners)Sweet 'N Low® (artificial sweeteners)Fried FoodsFried ChickenFrench FriesChips (Crisps)
DoughnutsVegetable Cooking OilsCheeseMilkYoghurtLobsterClamsShrimpPrawnsSquidOctopusHamBaconHot DogsSausagesCold Cuts and Prepared MeatsWhite Meats (Fish & Chicken)Red Meats (Beef, Lamb, etc)

Your Health

Please provide an overview of the current state of your health.






YesNon/a


YesNon/a

Are you experiencing any of the following (please check all that apply)?

Allergies or IntolerancesPainAscites or Edema (fluid retention)Metal Fillings (amalgam, nickel, etc)Hearing ProblemsDizzinessVertigoTinnitusHeadachesNeck/Shoulder/Back Pain or TensionImplants (Breast, Lips, Eyebrows)Excessive Weight LossInsomniaNightmaresUrinate more than twice a nightCold Feet
High Blood PressureLow Blood PressureIndigestion / Bloating / HeartburnUrinary InfectionsConstipationHaemorrhoidsShort-TemperednessIrritabilityNervousnessAnxietyDepression or other Mental IllnessProblems eating or swallowingConfined to wheelchair or bedTrouble climbing one flight of stairsMy job requires a lot of standingMy job requires a lot of sitting




On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

12345678910


If you have metal fillings, how many?

123456789More than 10

If you are a smoker, how many cigarettes do you smoke per day?

Less than 55 to 1010 - 2020 - 30More than 30

If you have tattoos, how many?

123456789More than 10




Your Declaration

By ticking this box, you agree to our terms of service and privacy policy regarding how we use your personal data.

Yes - I agree to the Budwig Center Terms of Service and Privacy Policy

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