MMM - Client Intake Form

Initial Intake Form

This intake form is for anyone with an initial Cold Laser Detox appointment
or Intuitive Wellness Guidance Consultation

Note: This form will take approximately 15 minutes to complete & must be completed in one sitting.
Your Appointment Date*

MonthDayYear
Full Name*

First NameLast Name
Pronouns

She/herHe/himThey/them
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile [Cell] Phone*

Area CodePhone Number
Phone

Area CodePhone Number
E-mail*
Date of Birth*
Referred by:*
Preferred method of contact*

Phone CallText MessageEmail
Occupation*

Top 3 Health Concerns*
Please write down your food and fluid intake for the last 24 hours.*
How many glasses of water do you drink daily?*
Type of Water

Municipal / Tap WaterWellBottled
Amount of sugar you eat daily (approx. teaspoons)*
Type of Sugar you eat*

NaturalArtificialNONE
Number of Alcoholic Drinks Daily*
Number of Caffeine Drinks Daily*
Number of Cigarettes Daily*
Number of Amalgam / Fillings*
Number of known Allergies*
Number of major past infections*
Number of major past injuries*
Number of car accidents*
Number of pounds overweight*
How much weight would you like to lose?*
Work Stress (Rate 1-10)*
Personal Stress (Rate 1-10)*
Consent

The following information is provided to this facility for nutritional information. The following being sought is of a nutritional nature and not a medical diagnosis, treatment, disease prevention, or health assessment. I hereby certify that I am not an employee, agent, or otherwise affiliated with the Federal Drug Administration, Health Canada, or a related agency. I further understand: According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "Drug" is defined to mean; Articles intended for use in the DIAGNOSIS, CURE, MITIGATION, or PREVENTION of disease. In other words, to "say" that vitamin, mineral, trace, or amino acids will have any effect on disease or symptoms thereof, that a particular nutrient then becomes a DRUG under the law as written. Therefore, any suggested nutrition is not intended as primary therapy for any disease or symptom but is provided safely to upgrade the quality of foods delivered through the diet. By providing information you are aware that you are consenting for information to be used under the name ViralScore TM - Nutritional Self Evaluation. Information provided will be used for the statistical gathering of data purposes only. No confidential information obtained will be used for any other purpose other than the ViralScore TM program.

Intuituve Wellness Guidance Consultation: I understand that no physician-patient relationship is established through my participation in this consultation. I also understand that this consultation is not psychotherapy. During this educational consultation, a list of available options or solutions will be described, but I agree that before undertaking any of these options or solutions, I will consult my physician or other health care practitioner whose care I am currently under. Recommendations are not meant to be taken as medical advice, nor is the information here complete enough by itself to make accurate or wise treatment decisions. Please talk with an appropriately trained healthcare provider before using these or other herbal medicines. I understand that an Intuitive Wellness Guidance Consultation is not a medical diagnosis, medical treatment, or medical advice; therefore, I understand that an Intuitive Wellness Guidance Consultation will not provide prescription, treatment or psychotherapy.
By checking this box I certify that I have read, understand and consent to the ViralScore TM Consent above.*

I consent

Thyroid Symptom Survey
Please Rate Symptoms as follows:

0 - I do not have this | 1 - Mild | 2 - Moderate | 3 - Severe
Hypo-Symptoms
Lumps in breasts*
More tired & sluggish than normal*
Drier hair & skin than normal*
Sleep more than usual*
Weaker muscles*
Colder than others*
Muscle cramps more than usual*
Poorer memory*
More depressed*
Slower thinking*
Eyes are more puffy*
Math is more difficult*
Hoarse or deeper voice*
Constipated more often*
Coarser hair*
Puffy hands or feet*
Unsteady when walking*
Gain weight easily*
Outer third of eyebrows thin*

Next three symptoms are for menstruating females.

If this does not apply to you then all zeros.
Lumpy/fibrous breasts*
Menses more irregular*
Heavier menses*
Hyper-Symptoms
Tachycardia*
Palpitations (skipping of heart)*
Insomnia (can't sleep well)*
Tremors (shaking)*
Increased sweating*
Brittle nails*
Loss of appetite *

By checking this box, I certify that I have read and understand the statements above and take full responsibility for my personal health and well-being.

I agree with the above terms and conditions
Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

	YES	NO
1. Do you wear a pace maker?
2. Do you have a battery operated or electronic implant?
3. Are taking blood pressure medication?
4. Are you taking seizure medication?
5. Are you taking depression medication?
6. Are you taking medication to maintain blood levels?
7. Are you pregnant?
8. Are you lactating or nursing?
9. Do you have open wounds or sores on your feet?
10. Have you received an organ transplant?
11. Are you prone to psychotic episodes?

General Medical Information

Previously Diagnosed Conditions

Acidosis / Chemical-Heavy Metal Toxicity Assessment

Thyroid Symptom Survey

Urgent Medical Information