Wellness Intake

Wellness Intake

Praciting Nature's L.A.W.S (Land, Air, Water, Spirit,)
Name

First NameLast Name
Phone Number
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Email
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Which of our services are you interested in?

Hair RestorationHealth and WellnessFinancial Wealth
How did you hear about us?

Existing ClientRadioOnline searchDr. referralStylist/SalonOther
What do you hope to achieve during your consultation?
Upload photo of any health condition for review by our medical professional

Please include any areas of concern you would like to discuss
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Status

MarriedSingleRecently Divorced (3yrs or less)Domestic violence (current or prior)
We ask the financial decision maker be present during the consulation. Are you the financial decision maker?
Which payment option works best for you*

Out of pocketCarecreditHSA/FSA
Are you open to all natural solutions

HerbsEssential oilsLight therapySound therapyNone of the aboveOther
Have you received Covid vaccination*
Have you experienced any of the following post vaccination*

Foggy brainDaily aches and pains from prior injuriesIrregular mensesDifficulty rememberingAnxietyDecreased Will to liveIncreased worryYes I test regularlyWish more people would wear their masksGet my regular booster shotsNone of the aboveOther
Did something trigger your health
What areas of stress do you have in your life

WorkChildrenFamilyFinancesHealthEducationCareer ChoiceRelationshipPhyscial Activity
Any unusual stress or recent life changes
What makes you feel better
What positive changes are you making in your life
Are you open to all natural plant based medicine for therapy
What are your stress relievers
At what age did you notice this condition and how long have you been experiencing the symptoms
Are the symptoms getting worse
Are your currently working with a Naturopath or Integrative physician? His or her name?
Is your condition acute (sudden) or chronic (ongoing)
Do you have a current outbreak or is it currently dormant?
Other options you have already tried
Do you sleep with the TV
What EMF devices do you own

Smart TvSmart refrigeratorRing house monitorAlexa or similiarOther
Any allergies to*

CopperNickelNeodymium magnetsYes, I have a pacemaker
Health Education

Healing is within
If you are monitoring your levels, hear what others have to say:
- Dr. John Bergman. Pharma controls you. https://youtu.be/rv1zD5PAiQg
- Dr. John Bergman. Blood pressure and cholesterol. https://youtu.be/PXe2xldWxtY
- Dr. John Bergman. Colonoscopies. Good or Bad. https://youtu.be/sRHbhCS01zA
- Dr. Peter Glidden. 3rd leading cause of death. https://youtu.be/xNVs_ClVw7U
- Dr. Brook Goldner. Lupus lecture. https://youtu.be/8NTgD8c9glM
- Dr. Burzynski. Cancer in America. https://youtu.be/rmxUsAI29fw
- Dr. Bruce Lipton. Heal yourself. https://youtu.be/1dyqHr2letc
- Clay Morris. Covid coverup. Did our loved ones live longer or expire sooner. https://youtu.be/ERvURcpg3JE
Disclaimer and Release

Health Disclaimer and Model release
I understand MHR LLC does not claim to heal, treat, cure, or diagnose any medical condition. I understand MHR LLC is not claiming to be a medical office, clinic, or profession. Any information gathered or conversation shared is solely for the purposes of suggestions and/or recommendations of my own free will. I am encouraged to seek medical advise for any the suggestions, recommendations, and especially for any serious or life threatening conditions.

I give consent for MHR LLC to use my case study, images, photos, and likeness for training and promotional purposes without compensation of any kind
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Wellness Intake

Health Education

Disclaimer and Release