Total Wellness Empowerment
Practitioner Lab Intro Training
Intake Forms
Here are the intake forms to choose from for you client.
The Medical Symptoms Questionnaire 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.
- Client Intake Questionnaire
Functional-Medicine-Initial-Intake-Forms to have your client complete.
This is a fillable intake form that you can send to your client and they can email back to you.
- 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 |
- 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 QUESTIONNAIRE
Client Intake Form/ Depression, Anxiety, and Stress Intake Forms
- 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
This questionnaire helps clients gain insights into their current self-care habits and areas where they can focus more attention.
- Daily Activity Questionnaire
This questionnaire encourages clients to take a closer look at their daily habits and their impact on well-being.
- Exercise History Questionnaire
This questionnaire provides valuable insights to help create a personalized exercise plan aligned with the client’s health, goals, and preferences.
- Toxic-Exposure-Questionnaire
This questionnaire provides a starting point for understanding a client’s toxin exposure and guiding further discussions on detoxification and health optimization.
- 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.