New Client Questionnaire

Hi. I am excited to be working with you on your Mineral-Nutritional Balancing Journey! To get started, please fill out all the information in this form. You can preview your entries before submitting. All the information you input is between you and me.

New Client Input Form

Hi. I am excited to be working with you on your Mineral-Nutritional Balancing Journey! To get started, I need you to fill out all the information in this form. The information is kept private. This is a multi-page form. Please fill out all the information in this form. Thanks!

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Name

First

Last

Confirm Email

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone Number

If you are out of the US, please enter your country code.

Birthdate (MM/DD/YYYY)

Age

Weight (in pounds)

Height

Gender

Female
Male

Occupation

How did you learn about me?

Consent

I understand the terms & conditions listed below

I understand that: 1) Mineral-Nutritional Balancing is a means to reduce stress and balance body chemistry. 2) Rosemary Slade is not a medical doctor. 3) Nothing here is intended to discourage me from seeking or following the advice of a medical doctor. 4) This is not meant to diagnose, treat or cure any diseases and isn’t a substitute for standard medical care.

What are your main health concerns or conditions?

Write the details of your health history starting when you can remember feeling well and on from there. Include any vaccinations, illnesses, and trauma and their approximate dates.

What medications and/or supplements are you currently taking? (Include Botox/Dyport if using now or used in the past.)

You can upload files later in this document if you prefer.

List any ‘out of range’ (high or low) results from recent medical tests (e.g., blood tests).

You can upload files later in this document if you prefer.

List illnesses in your immediate family (e.g., heart disease, cancer, TB, diabetes, arthritis).

What kind of movement/exercise do you do and how often?

Approximately how many hours of sleep do you get each 24 hours and what is the quality?

List any therapies, diets, supplements, medications, etc. that you’ve found helpful.

List any therapies, diets, supplements, medications, etc. that haven’t worked well for you.

Diet

What are examples of typical breakfasts for you (including beverages)?

Proteins, Vegetables (if any), Grains (if any) and Beverages

Mid-morning snacks?

Fruit? Popcorn? Chips? Nothing?

What are examples of typical lunches for you (including beverages)?

Proteins, Vegetables (if any), Grains (if any) and Beverages

Mid-afternoon snacks?

Fruit? Popcorn? Chips? Nothing?

What are examples of typical dinners for you (including beverages)?

Proteins, Vegetables (if any), Grains (if any) and Beverages

Evening snacks?

Fruit? Popcorn? Chips? Nothing?

Health Issues & Life Experiences Questionnaire

Male

Not applicable
Impotence
Prostate problems

Select all that apply

Trauma

Not applicable
Abuse-emotional
Abuse-physical
Abuse-sexual

Upload relevant files

Click or drag files to this area to upload. You can upload up to 5 files.

If you have any blood tests or other relevant information you think would benefit the discussion, please upload.

Comments

Disclaimer: The information contained on this website is not to be considered a substitute for regular medical care OR a means of diagnosis, treatment, prescription, or cure for any disease or condition—mental or physical. Please call your doctor for medical care.

Rosemary Slade OTR, PLLC, NC.