Total Wellness Empowerment
Practitioner Lab Intro Training
Intake Forms
Here are the individual intake forms to choose from for you client.
One is for a Child (there are two for a child, one is general and the other includes questions about toxin exposure).
Female Intake
Male Intake
The Medical Symptoms Questionnaire (MSQ) is an intake form that I would also have your client complete so you can gain insight into the current health issues they are experiencing.
Depending on the client and what health condition they are experiencing you can provide the specific health condition intake forms or you can wait until you get the test results to have them complete those specific ones.
All of the intake forms will help you gain pieces of the client's health puzzle.
Medical Symptoms QuestionnaireMedical Symptoms Questionnaire to have your client complete.
- Health Empowerment Questionnaire
Being empowered to take control of your health is one of the most effective ways to ensure that you are successful in your wellness journey.
- Female Intake Questionnaire
Female Intake Questionnaire to have your client complete.
- Male Intake Questionnaire
Male Intake Questionnaire to have your client complete.
- Male Intake Questionnaire (Hormone Related)
Male Intake Hormone Questionnaire to have your client complete.
- CHILD Intake Form
Child Intake Form to have your client complete; if under 18 years of age, then must have caregiver or parent complete form.
- CHILD TOXIN EXPOSURE QUESTIONNAIRE
Child Intake Questionnaire to have your client complete; if under 18 years of age, then must have caregiver or parent complete form.
Health Conditions |
- HPA Axis Questionnaire (Cortisol)
The hypothalamus, pituitary, adrenal (HPA) axis is the body’s central stress response system. This questionnaire is designed to help assess and differentiate possible dysfunction within this system.
- Adrenal Fatigue QUESTIONNAIRE
Answering these questions and adding up the scores will help decide if adrenal fatigue may be contributing to one's health problems.
- Adrenal Fatigue LONG QUESTIONNAIRE
Answering these questions and adding up the scores will help decide if adrenal fatigue may be contributing to one's health problems.
Longer Adrenal questionnaire.
- Depression Anxiety Stress Scales/QUESTIONNAIRE
Depression Anxiety Stress Scales
- Depression-Anxiety-Stress-Scales-Score-Sheet
Depression-Anxiety-Stress-Scales-Score-Sheet
- Healthy GUT QUESTIONNAIRE
Answering these questions and adding up the scores will help decide if the gut may be contributing to one's health problems.
- Metabolic Health QUESTIONNAIRE
Answering these questions and adding up the scores will help decide if metabolism may be contributing to one's health problems.
- Candida Screening QUESTIONNAIRE
Answering these questions and adding up the scores will help decide if candida/yeast may be contributing to one's health problems.
- Toxicity and Medical Symptom QUESTIONNAIRE
Helps identify root cause of toxins with reference to specific symptoms.
- Environmental Exposure History QUESTIONNAIRE
We are surrounded by toxins.
This will help identify Environmental-Exposure-History with regard to one's total wellness.
- Sleep Apnea Screening Questionnaire
Sleep Apnea Screening Questionnaire
- Self Care Questionnaire
Self Care Questionnaire
- Daily Activity Questionnaire
Daily Activity Questionnaire
- Exercise History Questionnaire
Exercise History Questionnaire
- Toxic-Exposure-Questionnaire
This Toxic-Exposure-Questionnaire is divided into the following sections:
Food & Water
Home & Work Environment
Travel & Recreation
Medical & Personal Care
- Dirty Genes Questionnaire
If these guys are dirty—whether born dirty or just acting dirty—the rest of your genes will be gunked up, too. Some dirty genes are hard to scrub. Not these seven. They are easily cleaned up through diet and lifestyle changes.
Being born with dirty genes has an upside as well as a downside. Born-dirty genes might put you at risk for some nasty health challenges— but they also help to shape your personality, activating strengths as well as weaknesses.
Your goal is to work with diet, chemical exposure, and lifestyle to maximize the benefits while minimizing the drawbacks.