Retest Client Questionnaire

It's time for a Hair Mineral Analysis Retest! 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

Email *

Confirm Email

Date (MM/DD/YYYY) *

Age *

Phone Number *

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

Height *

Weight *

Personalized Active Care Plan (PACP)

On a scale of 0-5, how closely have you been following your Personalized Active Care Plan?  0 = not at all, 5 = doing well

Coffee Enema *

Diet *

Dry Skin Brushing *

Meditation *

Sauna/Sauna Light *

Supplements *

Sleep *

If you have any comments on how you have been following your PACP please let me know.

How Have You Been Doing?

Describe changes you’ve noticed in your symptoms or condition since you began your Personalized Active Care Plan. *

Do you have questions about your supplements and detoxification procedures? *

Is anything interfering with your ability to follow the program? *

Is there anything else you want me to know as I update your Personalized Active Care Plan? *

Any files to upload? Recent lab work, etc..

Drag & Drop Files, Choose Files to Upload

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

Conditions/Symptoms (select all that apply) *

Acne
Addiction-alcohol
Addiction-other substances
Addiction-other
Allergies-other than food
Anemia
Anger
Angina
Anxiety
Arteriosclerosis
Arthritis -osteo
Arthritis -rheumatoid
Asthma
ADD/ADHD
Autism
Bipolar disorder
Bloating
Blood pressure-low
Blood pressure-High
Body temperature-low
Brain fog
Bronchitis
Bruising-easy
Bursitis
Cholesterol-high
Circulation-poor
Cirrhosis
Cold-feeling of
Colitis
Confusion
Constipation
Cough
Depression
Dermatitis
Development-delayed
Diabetes
Diarrhea
Diverticulitis
Dizziness
Dry Skin
Dyslexia
Eczema
Emphysema
Eyes-cataracts
Eyes-glaucoma
Eyes-macular degeneration
Fatigue
Fear
Fissures
Food-allergies
Food cravings-fats
Food cravings-starches
Food cravings-sweets
Food-cravings-other
Food-can't skip meals
Fractures
Gallstones
Gout
Hair loss
Headaches-migraine
Headaches-sinus
Headaches-tension
Heart attack
Heart-atrial fibrillation
Heart-palpitations
Heart rate-rapid
Heartburn
Hemorrhoids
Hives
Hunger-excessive
Hunger-little to none
Hyperkinesis
Hyperglycemia
Hypothyroidism
Infection-bacterial
Infection-fungal (e.g. Candidiadis)
Infection-urinary tract
Infection-viral
Infertility
Intestinal gas
Irritability
Irritability-before meals
Joint pain
Joint stiffness
Kidney infection
Kidney Stone(s)
Learning disability
Memory-poor
Meniere's disease
Mind racing
Mood swings
Multiple sclerosis
Muscle-cramps
Muscle-pain
Muscle-weakness
Neuritis
Obsessive/compulsive
Osteoporosis
Panic attacks
Parkinson's disease
Postnasal drip
Psoriasis
Schizophrenia
Scleroderma
Seizures
Sinus-congestion
Sleep-insomnia
Sleep-disturbance
Smoking
Stomach pain
Sugar reactions
Suicidal thoughts
Teeth-decay
Teeth-dental amalgams
Teeth-excessive plaque
Teeth-gum disease
Triglycerides
Tumour(s) / cancer
Ulcer
Urination-frequent
Urination-painful
Vertigo
Water retention
Weight-tend to gain
Weight-tend to lose
Wound healing-slow
Yeast infection

Male *

Not applicable
Impotence
Prostate problems

Select all that apply

Female *

Not applicable
Breasts-fibrocystic
Breasts-tumors
Fibroid tumors
Hot flashes
Menopause
Menstruation-none
Menstruation-heavy
Menstruation-Irregular
Menstruation-light
Menstruation-cramps
Ovarian cysts
Pap smear-abnormal
Pregnant-currently
Premenstrual syndrome
Yeast infection

Select all that apply

Trauma *

Not applicable
Abuse-emotional
Abuse-physical
Abuse-sexual

Comments

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Rosemary Slade • Wild Rose Texas Retreat • Waller / Magnolia / Montgomery County Region

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Disclaimer: All content on this website, in my videos, and on my social media pages is for informational purposes only. It is not medical advice and should not be used to diagnose or treat any condition. Please speak with your physician before beginning any exercise, wellness, or nutrition plan, particularly if you are pregnant, breastfeeding, managing a medical condition, or taking medication. Your healthcare provider is the best source for medical guidance and care.