Individual Body Landscape Consultation

Individual Body Landscape Consultation: $240 USD

Body Landscape Nutritional Consultation is available either in person, or via video chat (Zoom, Skype, or FaceTime), or Phone (USA and Canada) or free international calling apps. Includes written documents and an audio recording of the consultation.
All information provided will be kept strictly confidential.

Order Online: Fill out the intake form below (scroll down)

Follow-up consultations are available in person, or via Zoom, Skype or FaceTime, or by phone (USA or Canada only), or free international calling apps: $95 USD for 40 minutes. By appointment only.

Questions before ordering? Schedule a complementary 15 minute call with Jaguang here: Schedule Free Information Call

Order By Mail:

To order by mail, please download the Order Form (PDF), complete all information and mail with a check or money order for $240 USD. Personal checks will have a two week processing delay.

Make money orders payable to:
Sixth Ancestor Zen Center
307-250 Gorge Rd. West, Victoria BC, Canada V9A 1M6

Order Online
Name*
Salutation First Last
Gender*
- Male
- Female
Address*
Address Line 2
City*
State / Province / Region*
State / Province / Region
Postal / Zip Code*
Country*
Country
Phone Number*
Email*
- Send a copy of this message to yourself
DOB*
Time*
Calendar*
- Western (solar) Calendar
- Chinese (lunar) Calendar
Accuracy*
- Exact
- Approximate
- Per Birth Certificate
- Unavailable
The above time is:*
- Local Standard Time
- Local Daylight Savings Time
- Adjusted one hour back to Standard Time
- Don’t know
Location of Birth*
City State / Province / Region Country
What do you usually eat for breakfast?
Lunch?
Dinner?
Snacks?
How many times do you snack per day?
How many meals do you eat per day?
Are you currently following a diet regimen? If so, please describe*
Stamina: In general would you say you are a person of*
- High Energy
- Moderate Energy
- Low Energy
How often do you exercise?
Smoking?*
- Yes, I currently smoke
- No, I have never smoked
- Smoked but have quit
- Occasionally smoke (not daily)
Alcohol Consumption?*
- Never
- Occasionally
- Often
If often, How many times per week?
Have you ever been addicted to alcohol?*
- Yes
- No
Have you ever been addicted to non-prescription drugs/street drugs?
- Yes
- No
How many cups of caffeinated beverages do you drink per day?*
(Select the type of beverage and then enter the number of cups)
- Not Applicable
- Coffee
- Black or Green Tea
- Other
Number of cups:*
Please list any medications you are currently taking:*
Prescription start date:
DD slash MM slash YYYY
Please list all vitamins, supplements, and herbs you are currently taking*
Health Questionnaire
Please indicate any symptoms you currently have:
- High blood pressure
- High Cholesterol
- Diabetes
- Cancer
- Heart problems
- Heart attack
- Chest pain
- Shortness of breath
- Chronic cough
- Asthma
- Respiratory allergies
- Sinusitis
- Nose bleeds
- Gum disease
- Cold sores
- Canker sores
- Skin allergies
- Skin rash
- Food allergies
- Blood clots
- Uclers
- Frequent indigestion
- Nausea
- Vomitting
- Acid reflux
- IBS
- Constipation
- Diarrhea
- Appendicitis
- Decreased appetite
- Abdominal pain
- Blood in stools
- Gall stones
- Hepatitis or jaundice
- Liver problems
- Kidney Stones
- Kidney infection
- Bladder infection
- Incontinence
- Blood in urine
- Frequent urination
- Painful urination
- Prostate problems
- Uterine problems
- Hearing loss
- Ringing in the ears
- Ear aches
- Dizziness
- Fainting
- Low back pain
- Neck pain
- Leg cramps
- Restless legs
- Swelling in arms or leg (edema)
- Scoliosis
- Depression
- Insomnia
- Stroke
- Hyperthyroidism (overactive)
- Hypothyroidism (underactive)
- Vision Disability
- Osteoarthritis
- Rheumatoid arthritis
- Joint pain
- Chronic fatigue
- Fatigue
- Headaches
- Migraines
- Low grade fever
- Anxiety
- Fear
- Anger
- Worry
- Sadness
- Impatience
- Gout
- High Blood Pressure (hypertension)
- Low Blood Pressure (hypotension)
Please indicate any symptoms you have had in the past:
- High blood pressure
- High Cholesterol
- Diabetes
- Cancer
- Heart problems
- Heart attack
- Chest pain
- Shortness of breath
- Chronic cough
- Asthma
- Respiratory allergies
- Sinusitis
- Nose bleeds
- Gum disease
- Cold sores
- Canker sores
- Skin allergies
- Skin rash
- Food allergies
- Blood clots
- Uclers
- Frequent indigestion
- Nausea
- Vomitting
- Acid reflux
- IBS
- Constipation
- Diarrhea
- Appendicitis
- Decreased appetite
- Abdominal pain
- Blood in stools
- Gall stones
- Hepatitis or jaundice
- Liver problems
- Kidney Stones
- Kidney infection
- Bladder infection
- Incontinence
- Blood in urine
- Frequent urination
- Painful urination
- Prostate problems
- Uterine problems
- Hearing loss
- Ringing in the ears
- Ear aches
- Dizziness
- Fainting
- Low back pain
- Neck pain
- Leg cramps
- Restless legs
- Swelling in arms or leg (edema)
- Scoliosis
- Depression
- Insomnia
- Stroke
- Hyperthyroidism (overactive)
- Hypothyroidism (underactive)
- Vision Disability
- Osteoarthritis
- Rheumatoid arthritis
- Joint pain
- Chronic fatigue
- Fatigue
- Headaches
- Migraines
- Low grade fever
- Anxiety
- Fear
- Anger
- Worry
- Sadness
- Impatience
- Gout
- High Blood Pressure (hypertension)
- Low Blood Pressure (hypotension)
When did these symptoms begin?*
How long have you had these symptoms?
Please list any surgeries you have had:*
When did you have these surgeries?
Please list any other current health symptoms or concerns:*
How did you hear about us?
Please provide my consultation by:*
- In Person Appointment
- Video Chat (Skype or FaceTime)
Video Chat Preference:*
- Zoom
- FaceTime
- Skype
Payment
Individual Body Landscape Consultation
Price:
Total
$0.00
Payment Method*
(Select your preferred method of payment to complete your order)
- Pay with credit card or Paypal
- Mail a check or international money order
Documents for your consultation will be emailed to you prior to your appointment.
Click Submit to create a printable custom form.