Detox Shoppe

Detox Shoppe Health Questionnaire

Health Begins at Home
How did you hear about us?

Joyce BakerFacebook Group Please specify Group Name if known ie; Lyme group, Heavy Metal Detox etcFriend or FamilyOnline Google searchOther
I was referred by
Name

First NameLast Name
Client’s Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
(Please make sure this is an email you check regularly as we may use as correspondence from time to time).
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
What is the best way to communicate with you or your guardian?
Date

MonthDayYear
Date
WOULD YOU LIKE YOUR PRODUCTS SHIPPED TO THE ABOVE ADDRESS?
If you answered No. Please indicate where we should ship your products or if you be arranging pick up.
Name

First NameLast Name
In case we ship products to you, please put down your shipping address if different than above address. We currently only ship in the United States with exception of Hawaii. If address is the same put same as above.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MARITAL STATUS
If applicable
ARE YOU EMPLOYED:
CURRENT TREATING PHYSICIAN
CAN WE CALL YOUR PROVIDER IF WE NEEDED TO?
PLEASE LIST ANY VACCINES YOU HAVE TAKEN
Include medications, food, perfumes latex etc.
PLEASE LIST ALL ALLERGIES AND REACTIONS YOU HAVE (include vaccine reactions if applicable)
Include medications, food, perfumes latex etc.
Have you had the Covid Vaccine? If Yes, How many have you had please include boosters.(include vaccine reactions if applicable)
Include medications, food, perfumes latex etc.
LIST ALL ALLERGIES MEDICATION AND FOOD, POLLENS OR SEASONAL AS WELL.
Include medications, food, perfumes latex etc.
RESULTS OF PAST TREATMENTS/SURGERIES, SERIOUS AILMENTS OR CONCERNS
Put N/A if no concerns.
Have you consumed any of the following on a regular basis more over the last 7 days. Check all that apply

Sugar or sweets, cookies, candies, ice cream or sodaProcessed foods things that come in boxes or premadeDairyGlutenPorkFoods with nitratesFast foodFried foodCandy bars or ice creamI am unable to eat regular food due to age or a conditionEnsure, Boost or premise nutritional drinks not organic (if formula please put name of formula for babies)Drinking and eating out of plasticUsed a microwaveOther
Have you had any of the following in the past year? check all that apply

SushiEnergy DrinksTap waterWell WaterFoods that have additional preservatives. Examples are, Sugary cereals, prepackaged items or premaid meals life stouffers.Exposure to toxic chemicals in your employmentI am unable to eat solid food due to age or a condition.Have you been exposed to any substance that you feel is impacting your health negatively (list below)Other
Are you aware of the negative impact of Fluoride and Chlorine on health?
How many times a day do you eat fruit?

I eat 2-4 servings dailyI eat 1-3servings dailyI rarely eat fruitsIf I eat fruit I usually eat; please state belowOther
Are their any types of foods or drinks you need to stay away from because of a suspected or known allergy?

yesnoI am not sureI suspect I have some food allergies and would like to know more.I avoid the following food or foods please list below and reasonOther
How many times a day do you eat vegetables?

I eat at least 5-7 vegetables dailyI eat 3-5 VegetablesI eat 1-3 vegetables dailyNone or I rarely consume vegetablesOther
Have you been diagnosed or seen for long term digestive complaints?
Have you lost or gained 10 lbs or more in the last 6 months

I have gained 10 lbs or moreI have lost 10 lbs or moreI have not lost or gained anything significant
Do you have have difficulty digesting certain foods like protein or fats?
Please specify if you eat a special diet for example, Pegan Vegan, Vegitarian, Paleo, Ketogenic, Diabetic
Where do you typically have pain? (check all that apply)

all over my bodymy pain moves aroundjoint painneck painMy pain is due to an accidentI have burning in my extremitiesI do not have any pain or rarely doI have headaches mainlyI wake up stiff oftenI have Chronic pain and need to take medication for thisOther
Please rate your pain from 0-10 today
Have you ever had a fall that resulted in an injury?

yesnoOther
If yes, did your fall result in a concussion/head injury or other injury that your are aware of?

yesnoIf yes, please put the injury, any surgeries needed due to fall or treatments or mental or behaviorial issues due to head injury or if not head injury any area that’s was affected that you still have issues or concerns with.Other
Do you have nausea or bloating after you eat?
How many bowel movements do you have a day?
Do you notice you can’t tolerate eating fiber or certain vegetables?
Have you been diagnosed with any autoimmune disorders?
If you are a female do you have your menstrual cycle?
Have you been told you have a thyroid condition before?
What are your sleep patterns like?
If applicable please explain any sleep issues below.
Do you wake up rested
Do you sweat at night?
Please let us know your level of functioning
Have you been diagnosed with the following? (check all that apply)

DiabetesHigh Blood PressureThyroidArthritisGoutLyme diseaseAutoimmune diseaseSjogrensArthritisLupusEpstein Barr or Chrinic Fatigue/FibromyalgiaMultiple SclerosisCancerLou Gehrig’s or ALSSeizuresHeart failureKidney FailureLiver FailureSeizuresAICDThyroidI get monthly infusions or treatments for a condition I have please specify below what infusion you receive and why.Anything else not listed put below or clarifynone of the aboveOther
Do you have any of the following current or past(check all that apply)

DepressionAnxietyOCD Obsessive Compulsive Disorder(diagnosed and require medication)OCD Obsessive Compulsive Disorder (diagnosed and not on medication)PTSDBipolarHistory of addiction to drugs or alcohol (if current addiction or chronic use of opiates like Percocet. Not something like a pain medication you take as needed once a week)Please specify any current or past addictions below.Please put the word current or past next to word below.Eating disorder diagnosedPossible eating disorder not diagnosedOther
If you answered you have Any mental health concerns. Are they currently well managed or are their concerns?
Please contact your consultant prior to appointment if mental health condition not well managed.
If you answered you have any addiction, serious mental health issues including eating disorders, please let us know if you need resources as we are not a detox clinic and we ask that all new clients with health challenges like addictions or that have been on opiates or medications or substances that cause dependency to make us aware so we can advise better. We want to help you so if taking opiates daily, psychiatric medication, alcohol daily or more often, severe eating disorder or mental health concerns we ask that you first have this under control and be in the care of a professional/s to assist you. We will discuss if our services can be a beneficial adjunct to your life to assist in your healing. By leaving blank and signing at the end of this form you are letting us know this is not a current concern of yours.
Please contact your consultant prior to appointment if addiction or condition not well managed. We take each client so needs with special care and want to ensure you are able to move in the proper direction to assist in your healing.
Please specify any other diagnosis if not listed
Do you currently have any of the following

I have one or more mercury fillingsI have had one or more root canals in my lifeI have had one or all of my mercury removed from my fillingsI had chelation done after my mercury removalI do not know if I have any mercury fillings.I have had a lot of dental work done in my life.Other
LAST TIME YOU HAVE SEEN YOUR PHYSICIAN APPROXIMATELY
ARE THEIR ANY CONCERNS THAT COULD STOP YOU FROM CONTINUING ON OUR PROGRAM?
How often are window cleaners, bleach, disinfectants, floor wax, furniture polish used in your home

NeverRarelyMonthlyWeeklyDaily
If you answered yes to above question regarding tap water please specify how often you drink tap water? Check all that apply

I rarely or never drink tap watera few times a weekdaily this is all I drinkI do a mixture or tap and bottled waterI only drink purified or reverse osmosis water or springI drink alkaline water oftenI have a high quality water filtration systemOther
Have you traveled out of the country in the last year

yesnoif yes, please state where you traveled and if you had any health issues during your trip or when you returned.
For infants and children, Was their any complications with the pregnancy? Please check all that apply.

yesnoI took prenatal vitaminsmy child was born prematureN/AOther
Do you feel your condition is urgent or requires emergency help right now?
If you answered you need urgent help, please take yourself or loved one to Emergency Room if Emergent or urgent care for immediate concerns. We are a Holistic Clinic and although we can work to bring about positive health changes, we can not guarantee results to be immediate. If you have questions before your appointment please contact your consultant.
For parents bringing infant or child to visit. Please put medical history, surgeries, and biggest issues right now.
We offer ZOOM health coaching as additional part of our services to better meet your goals at a discounted rate for current clients of the Detox Shoppe at a Discounted Rate! This includes: 4 modules Group Sessions are Every Other Week and highly intentional on healing and focus on you! We Have 12 topics we cover. 1.What is Detoxification and Why is it important. Learn how to incorporate 3 easy at home applications. 2. How to let your body safely rid of toxins. Receive Questionnaire (Many call this "Cleanse or Detoxification." 3. Lets talk Basic Health stuff! Vital Signs and what they actually mean to your health. Health Begins at Home and what this means! Chemical Toxicity, Water Purity, Emf's and Environmental Stress. 4.Stealth Pathogens like Lyme Illness Class How to learn practical self care routines at home. Keeps Clients on Track! Please specify if you would like to learn more about how JOINING THE 6 MONTH Detox DIY Health Coaching Program can achieve better long lasting results.

I would like to learn more information on how health coaching can help me.I want to finish the first consultation and see how I do.
Please list 3 things you would like us to help you with during your consultation and the first 3 months of the program. Examples, I would like help with weight loss, blood pressure, pain management, dietary changes, learn healthier lifestyle choice, I want more natural choices for health for my family; are a few examples.
Are you currently using any of the following. Please check all that apply.

VitaminsMineralsHerbsHomeopathyMany detoxification thingsI exercise a 3-5 days a weekEnergy workChiropracticPhysical TherapyCraniosacralDry needling for painTens units or other devices for painIf currently in chiropractic or Physical therapy put below how often you go and for what condition.I have not done any Natural things or alternative therapies.Please list any additional things you are currently doing or have done if you found them helpful.Other
Please Read and Sign our Terms and conditions for our products and services. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO ASK, I HOPE YOUR VISIT WILL BE BOTH EDUCATIONAL AND HELPFUL. Signing this form indicates that you are voluntarily and knowingly undergoing this procedure referred to as Computerized Electro Dermal Screening (EDS). This term involves the field of Quantumphysics which deals with energy fields that you cannot see with the naked eye. Dr.Reinholt Voll MD, of Germany, discovered Electro Dermal Screening around 1926. This procedure is currently conducted around the world in countries including the United States, Canada,Mexico, Germany, South Africa, Japan, Israel, England, Australia, and New Zealand. This procedure is totally non-invasive and involves the application of an electronic probe of 1.5 to 5 volts to measure skin resistance at selected acupuncture sites located on the hands and feet. It can be safely performed on an infant to the elderly person. During the procedure, it is then determined as to which meridians are imbalanced and which natural substances bring balance back to the meridians. The process allows your own body to "talk" to the practitioner. The procedure is completely safe. The only sensation that is felt is the slight pressure of the probe against the acupuncture site. Twenty-five plus acupuncture sites may be tested.The Food and Drug Administration (FDA) has classified this device, as a Class Two,which means it is information finding only, much like an EKG. At no time will there be any implied and/or stated indication for any client to discontinue any medication prescribed by his/her physician. EDS is not intended, implied, or stated to take the place of any medication test and/ordiagnostic procedure; but EDS is complementary to these tests and procedures. Thisoffice cannot guarantee complete resolution of all your health concerns, but ithas been found that complete client compliance to the suggested natural Healthcare recommendation can result in greater and more consistent changes toward better health. Insurance is not billable at this time for this procedure. I understand that Mary Jacobs is a nurse, not a traditional medical doctor. I have fully read and understand the above information, the elements of informed consent, my responsibilities and rights, and hereby consent to EDS also known as Meridian Stress Assessment. Mary Jacobs RN BSN PHC has certifications past and present pertaining to healthy living and has lectured at corporate settings, coached and educated patients, family and clients on healthy living for over 10 years. I consent to the discreet use of my clinical information as needed for study, teaching and research. We may utilize urine and hair samples specimens for our consultations for clients who cannot come into our office at the practitioners discretion. I understand by signing this form that any testing done on my urine or hair sample is not traditional lab work and considered energetic testing and the client will not receive a diagnosis for the testing that is being done. The purpose of the testing is to give information for the practitioner regarding the clients meridian state whether balance, weak or stressed to better help the client balance their normal bodies physiology.

Our program, consultations, advice or products are not intended to diagnose, treat or cure any disease.

This program is intended to assist the client in better management of their current disease or health by using natural modalities. I will do my best to work towards my goals to bring about positive change in my health and well being. I agree to make Mary aware if I am unable to continue this program.

I am aware that the Detox DIY Health Membership Program is an initial 3-month commitment program after the initial 3-months the practitioner and client discuss if goals are beginning to be met. We cannot guarantee goals will be met but the practitioner and client will discuss realistic goals to ensure they are obtainable. I am required to discuss a minimum of 3 concerns that I would like to be helped with and new concerns during upcoming visits.

I understand that chronic health concerns is something I have had six months or longer may take months or years to bring about a positive changed in some instances. I understand the purpose of this program is to help me improve my health through natural modalities for example, better nutrition, positive dietary habits, teaching me how to decrease toxic exposure in my life, discussion or emotional, mental and spiritual components of illness at times and how to adapt to make changes.

I understand that I may be referred to other health professionals at times to assist in meeting my health goals.
Are you aware that our program works to bring the Meridians back into balance? These are your energy circuits that connect to your organs. Please check all that apply.

YesNoI want to learn more during the visitI have a pacemaker or implant device for irregular heart rateI have history of seizuresI am pregnantOther
Our initial consultation is $265 for first 2 hours and $68 for each additional 30 minutes. We allow for 20-30 minutes to ring clients orders and for additional questions which is not charged to the client currently. Our follow up consultations are typically $135 for 60 minutes additional $68 for every 30 minutes. Our average fee for follow up visits $135-$250 depending on clients health concerns. If you have time constraints please let us know prior to your appointment. Nutritional Supplementation: vitamins, minerals, homeopathy, herbs, miscellaneous products are additional. We do offer payment arrangements for clients on restricted incomes must complete payment in two weeks from visit and split in 2 payments. We encourage Cash and Check if possible. We do not take American Express but we do take all other credit cards, cash and check. We reserve the right to charge $35 or bank fee for any checks that have Please let us know if you have additional questions or concerns prior to your appointment. Please call 216-402-7070. Thank you for partnering with Mary and the Detox Shoppe, LLC. We look forward to serving you and helping you become a more vibrant you!!
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Detox Shoppe Health Questionnaire