intake form / toxicity questionnaire
TRANSCRIPT
INTAKE FORM / TOXICITY QUESTIONNAIRE
SYMPTOM QUESTIONNAIRE (SQ)
Client Name _________________________________________________________________________________ Date ____________________________ Rate each of the following symptoms based upon your typical health profile for the past month:Point Scale: 0 - Never or almost never have the symptom 3 - Frequently have it, effect is not severe
1 - Occasionally have it, effect is not severe 4 - Frequently have it, effect is severe 2 - Occasionally have it, effect is severe
HEAD ___ Headaches ___ Faintness ___ Dizziness___ Insomnia
TOTAL _____________
EYES ___ Watery or itchy eyes___ Swollen, red or sticky eyelids___ Bags or dark circles under eyes___ Blurred or tunnel vision
TOTAL _____________
JOINTS/ ___ Pain or aches in jointsMUSCLES ___ Arthritis
___ Stiffness or limited movement ___ Pain or aches in muscles___ Feeling of weakness or tiredness
TOTAL _____________
ENERGY/ ___ Fatigue, sluggishnessACTIVITY ___ Apathy, lethargy
___ Hyperactivity ___ Restlessness
TOTAL _____________
EARS ___ Itchy ears___ Earaches, ear infections___ Drainage from ear___ Ringing in ears, hearing loss
TOTAL _____________
SKIN ___ Acne___ Hives, rashes, dry skin___ Hair loss___ Flushing, hot flashes ___ Excessive sweating
TOTAL _____________
HEART/ ___ Chest painVASCULAR ___ Irregular or skipped heartbeat
___ Rapid or pounding heartbeat___Blood Clots TOTAL _____________
EMOTIONS ___ Mood swings___ Anxiety, fear, nervousness___ Anger, irritability, aggressiveness___ Depression
TOTAL _____________
OTHER ___ Frequent illness___ Frequent or urgent urination___ Genital itch or discharge
TOTAL _____________GRAND TOTAL _____________
LUNGS ___ Chest congestion___ Asthma, bronchitis___ Shortness of breath___ Difficulty breathing___ Chronic Coughing
TOTAL _____________
MOUTH/ ___ Chronic coughingTHROAT ___ Gagging, frequent need to clear throat
___ Sore throat, hoarseness, loss of voice ___ Swollen or discolored tongue, gums, lips ___ Canker sores
TOTAL _____________
NOSE ___ Stuffy nose ___ Sinus problems ___Chronic sore throat___ Hay fever___ Sneezing attacks___ Excessive mucus formation
TOTAL _____________
G.I. TRACT ___ Nausea, vomiting ___ Diarrhea___ Constipation ___ Bloated feeling___ Belching, passing gas___ Swollen, red or sticky eyelids___ Intestinal/stomach pain___ Heartburn
TOTAL _____________
WEIGHT ___ Binge eating/drinking___ Craving certain foods ___ Excessive weight ___ Water retention___ Underweight___ Compulsive eating
TOTAL _____________
MIND ___ Poor memory___ Confusion, poor comprehension ___ Difficulty in making decisions ___ Stuttering or stammering
TOTAL _____________INFECTION ___Unexplained fevers, night sweats, chills, or flushing
___Swollen glands ___ chronic sore throat___Migratory muscle & joint pain___Treated for chronic fatigue syndrome w no improvement ___Unexplained sleep decline___Unexplained brain/mental health decline___Unexplained tingling, numbness, burning
TOTAL _____________
CHEMICAL TOLERABILITY TEST (CTT)
OVERALL SCORE TABULATION
TOXINS ARE EVERYWHERE!
KEY: UNDERSTANDING YOUR SCORE
1. Are you currently using prescription drugs?___ Yes (1 pt.)If yes, how many are you currently taking? ___ (1 pt. Each) ___ No (0 pt.)
6. Do you commonly experience “brain fog,” fatigue, or drowsiness?___ Yes (1 pts.) ___ No (0 pt.)
7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?___ Yes (1 pt.) ___ No (0 pt.) ___ Don’t know (0 pt.)
8. Do you feel ill after you consume even a small amount of wine?____ Yes (1 pt.) ___ No (0 pt.) ___ Don’t know (0 pt.)
9. Do you have a personal history of...___ Environmental/Chemical Sensitivities (5 pts.) ___ Lyme/MCIDS/Chronic Infections (5 pts.)___ Cancer Diagnosis_____________________________________ (5 pts.)___ Chronic Fatigue/Fibromyalgia (5 pts.) ___ MS /Parkinson’s Type Symptoms (5 pts.)___ Memory Decline/Cognitive Impairment (5 pts.)___ Auto-Immune Diagnosis _______________________________(5 pts.)
10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or chemical solvents?___ Yes (1 pt.) ___ No (0 pt.)
11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar, and vegetables?___ Yes (1 pt.) ___ No (0 pt.) ___ Don’t know (0 pt.)
2. Are you presently taking one or more of the following over-the-counter drugs?___ Ibuprofen (Advil) (2 pts.)___ Acetaminophen (Tylenol) (2 pts.)___ Prevacid for Heartburn(2 pts.)
3. If you have used or currently use prescription drugs, which of the following scenarios best describes your response to them:___ Experience side effects; are efficacious at lowered doses (3 pts.)___ Experience side effects; are efficacious at usual dose (2 pts.)___ Experience no side effects; usually are NOT efficacious (2 pts.)___ Experience no side effects; are usually efficacious (0 pts.)
4. Do you currently use or within the last six months had you regularly used tobacco products?___ Yes (2 pts.) ___ No (0 pt.)
5. Do you have strong negative reactions to caffeine or caffeine containing products?___ Yes (1 pt.) ___ No (0 pt.) ___ Don’t know (0 pt.)
SQ SCORE _____ (high >50; moderate 15-49; low <14) CTT SCORE _____ (high >10; moderate 5-9; low <4)
Toxins are everywhere. They are in our food, water, air, even our household goods...and they are destroying your health. EVERYONE has some level of mercury toxicity even if their amalgam fillings have been removed because so many folks still eat seafood. Aluminum has been linked to memory issues, breast cancer, Alzheimer’s disease, allergies, and even autism. The link between toxins and disease is now undisputed, but it’s still being ignored by conventional medicine. Fortunately, you can rejuvenate and detox yourself from these toxic chemicals & metals that you are being exposed to daily!
CLUB HEAL can help you reduce your toxic load with the CIRCUIT HEALING STATIONS & PRIVATE ROOM ADD-ONSCHOOSE YOUR PROGRAM TODAY AND START YOUR DETOX & REJUVENATION LIFESTYLE!
GRAND TOTAL _____________
SQ SCORE CTT SCORE PLAN OF ACTION50 or > 10 or > If both scores are HIGH: elevated toxic load indicated; Recommend more intensive detoxification; SUPERCHARGE or TRANSFORM MEMBERSHIP
39 or > 8 or > If both scores are in this MODERATE/HIGH RANGE: Recommend moderate detoxification; DETOX or SUPERCHARGE MEMBERSHIP
15 to 38 5 to 7 If both scores are in this LOW/MODERATE range: Recommend less detoxification; RECHARGE or DETOX MEMBERSHIP
14 or < 4 or < Congrats ~ MINIMAL TOXIC LOAD ~ keep doing what you are doing; recommend the circuit 1-2x/month for DETOX/ REJUVENATION MAINTENANCE
CLiENT iNFORMATiON ~ CLuB HEAL CiRCuiT
CLiENT iNFORMATiON ~ PRiVATE ROOM ADD-ONs/FAT MELTiNG/sKiN CARE
DOB: _____/______/______ Place of Birth (use for biofeedback testing purposes only) __________________________________________________________________________
ADDRESS:__________________________________________________________________________________ City:________________________ State:______ Zip:___________
Cell Phone #: ____________________ Phone Carrier for Text Confirmations:_______________Permission to contact you: o Phone o Text o Voicemail o Email oAll
Email: _________________________________________________________________________ Profession: ____________________________________________________________
Emergency Contact Name: ________________________________________ Relationship: _________________________________________ Phone #:______________________
How did you find us? o Social Media oWebsite o Yelp o Press oGoogle o Friend ____________________________________________________________________
oReferring Physician: _______________________________ for what condition/diagnosis _______________________________________________________________________
Surgeries:_____________________________________________________________________________________________________________________________________________
Do you have any of the following: o Pregnant o Pacemaker o Epilepsy o Spinal Fusions oCancer Diagnosis o Serious Medical Condition oBlood Clots
o Issues with sweating/or increasing heart rate o Issues with Bowel Elimination: ________/Day or ________ /Week
What is your primary health goal and/or challenge that you would like CLUB HEAL to help you with?
1234 5What kind of detox have you done in the past? o Juice o Fasting o Supplement Cleanse oDetox retreat oCleanse Program oOther:___________________Were you satisfied with the results? Y / N Did it help you feel better and rejuvenated? Y / NWhat would you like to get out of your detox session at CLUB HEAL
Have you used other devices/equipment to achieve fat reduction? Y / N Describe _____________________________________________________________________________
What kind of results did you get?_________________________________________________________________________________________________________________________
Have you ever had COLD LASER TREATMENTS for either medical and/or fat melting Y / N Results?_______________________________________________________________
Are you a smoker? ____________ Alcohol?____________ (both of these will impede your fat melting results)
Have you ever tried Zerona Fat Melting Laser? Y / N Results?_______________________________________________________________________________________________
Do you feel you look older than you are? Y / N Why? ______________________________________________________________________________________________________
Please list any facial and/or aesthetic surgeries/injections: ___________________________________________________________________________________________________
Fillers/Botox: _______________________________________________________________________________________ Last Date of Injection:_______________________________
Do you bruise easily? Y / N or On blood thinners? Y / N
Do you have any special skin problems or concerns pertaining to your face or body? Y / N
Please Explain:_________________________________________________________________________________________________________________________________________
Any Allergies?__________________________________________________ or sensitive to essential oils, collagen, stem cells, or hyaluronic acid? ___________________________
Have you ever tried Ozone Insufflation of ear or pelvic floor? Results _________________________________________________________________________________________
Do you have issues with o Edema o Post Surgical Swelling oCellulite o Lactic Acid Build Up o Poor Circulation o Lymphaedema
CHEMiCAL TOLERABiLiTY TEsT (CTT)1. Do you have a household mold problem?Yes ___ No ___
6. Have you ever been tested for toxicity ~ from workplace or home?___ Yes ___ No If yes, please list test(s)
7. Do you currently use any detoxification modalities, products, or protocols? If yes, please list
2. Do you use a microwave or get take out with plastic containers?Yes ___ No ___ How Many______ When removed?_______
3. Do you have silver dental amalgams in your mouth?Yes ___ No ___
4. How would you describe your cell phone use?2 or more hours daily ___ 1-2 hours daily ___ Less than one hour daily ___ ` keep on nightstand while sleep ___ keep WI-FI router on while sleeping ___
5. Do you live or work within 100 ft of high voltage electrical wires or cell phone tower?Yes ___ No ___ I’m not sure ___
TOXiN AWARENEss QuEsTiONNAiRE
oo
oooo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
oo
QUESTIONS YES NO
Do you use deodorant that contains aluminum?
Do you use chemically based make up, hair coloring products and body products?
Do you use a fluoride based toothpaste?
Do you drink unfiltered tap water? (vs filtered water)
Are your supplements purchased from Walgreens, GNC, Rite Aid, Walmart?
Do you shower with unfiltered tap water? (vs filtered tap water)
Do you use a Smart Meter on your home?
Are you being exposed to dangerous EMF frequencies with your cell phone?
Are you being exposed to dangerous EMF frequencies at your home/work place?
Do you eat from canned foods often?
Do you have a chlorinated hot tub/jacuzzi or pool?
Do you consume conventionally grown (non-organic) fruits and vegetables regularly?
Do you consume fish, sushi or seafood more than twice a week?
Do you consume conventionally raised animal products (meat, dairy, eggs) regularly?
Do you consume fast foods, canned/packaged foods, soda, or foods with artificial colors, flavors, preservatives or sweeteners more than three times a week?
Have you lived in a mobile home, boat, or RV, or a very old or brand-new home?
Have you recently been exposed to new construction materials or furniture(e.g., paint, laminate flooring, particle board, new carpeting, bedding, furniture, etc.)?
Does your home or workplace have cracking paint or decaying insulation or foam, visible mold, water damage, or damp windows, basement, or crawlspaces?
Are you often exposed to adhesives, paints, flea treatments, varnishes, solvents, welding/soldering materials or other airborne chemicals at home or work?
Have you been exposed to treated lumber, lead paint, paint chips or dust, broken mercury thermometers or fluorescent bulbs, or other toxic substances you know of?
Do you regularly use conventional cleaning chemicals, disinfectants, hand sanitizers, air fresheners, scented candles, or other scented products at home or work?
Have you lived in an agricultural area or often been exposed to herbicides, pesticides, fungicides at home, work, parks & golf courses, or roadsides?
Do you live or work in a sealed building with recirculated air or a building that has wood, propane, or gas stoves or appliances?
Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?
Are your health concerns related to time spent living or working adjacent to a highway, factory, incinerator, gas station, power plant, or other industrial pollution source?
Do you smoke or are often exposed to second-hand smoke, fly often, or run or bike to work along busy streets?
Have you had any unusual reactions to anesthesia or to prescription or over-the-counter medications?
Have you had root canals, tooth extractions, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays, braces, mouth guards, dental implants, etc.?
Do you use a cordless land line phone at work or home?
TOXIN AWARENESS QUESTIONNAIRE ~ CONTINUEDPlease check YES or NO for each of the following questions
Be aware that the items below that you answer yes to are adding to your overall toxicity levels
CANCELLATION POLICY
TOXIC LOAD ~ BLOCKS & CHALLENGES
CLUB HEAL REQUIRES A 24 HR NOTICE FOR ALL CIRCUIT SESSIONS & PRIVATE ADD ON SESSIONS- if you cancel less than 24 hours before the start of your session, we ask you to be financially responsible for the session. This means you need to email 24 hours before the start of the session (not the “night before”) to not incur charges. While we do feel personally sympathetic to issues that can arise, please consider your booking like a concert ticket since we are a boutique detox spa with limited space. Feel free to use it or not, as supports your best interests at the time. Without notice you agree to have your scheduled services deducted from your circuit membership or private session package or if doing a pay each time- 50% of total charges for what you had booked.
I agree to the above cancellation policy and that my credit card may be used to handle all cancellation issues
NAME:_________________________________________________ SIGNATURE:____________________________________________________ DATE:_____________________
KEY:h - SCARSHHH- PAIN000 - SURGERIES & WHAT KIND+++ - INJURIESs s s - EDEMA/SWELLINGXXX - BLOCKED AREAS
© CLUB HEAL / ALL RIGHTS RESERVED