MMM - Client Intake Form

Initial Cold Laser Detox Form

This ViralScoreTM form is for anyone with an initial cold laser detox appointment

Note: This form will take approximately 15 minutes to complete & must be completed in one sitting.
Your Appointment Date *

Month Day Year Date Picker Icon
Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
E-mail *
Date of Birth *
Occupation *

Please write down your food and fluid intake for the last 24 hours. *
How many glasses of water do you drink daily? *
Type of Water *

Municipal / Tap Water Well Bottled
Amount of sugar you eat daily (approx. teaspoons) *
Type of Sugar you eat *

Natural Artificial NONE
Number of Alcoholic Drinks Daily *
Number of Caffeine Drinks Daily *
Number of Cigarettes Daily *
Number of Amalgam / Fillings *
Number of known Allergies *
Number of major past infections *
Number of major past injuries *
Number of car accidents *
Number of pounds overweight *
How much weight would you like to lose? *
Work Stress (Rate 1-10) *
Personal Stress (Rate 1-10) *
Viral ScoreTM Consent

The Following information is provided to this facility for nutritional information. The following being sought is of a nutritional nature and not a medical diagnosis, treatment, disease prevention, or health assessment. I hereby certify that I am not an employee, agent, or otherwise affiliated with the Federal Drug Administration, Health Canada, or a related agency. I further understand: According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "Drug" is defined to mean; Articles intended for the use in the DIAGNOSIS, CURE, MITIGATION, or PREVENTION of disease. In other words, to "say" that vitamin, mineral, trace or amino acids will have any effect on disease or symptoms thereof, that a particular nutrient then becomes a DRUG under the law as written. Therefore, any suggested nutrition is not intended as primary therapy for any disease or symptom, but is provided safely to upgrade the quality of foods delivered through the diet. By providing information you are aware that you are consenting for information to be used under the name ViralScore TM - Nutritional Self Evaluation. Information provided will be used for statistical gathering of data purposes only. No confidential information obtained will be used for any other purpose other then the ViralScore TM program.
By checking this box I certify that I have read, understand and consent to the ViralScore TM Consent above. *

I consent

Thyroid Symptom Survey
Please Rate Symptoms as follows:

0 - I do not have this | 1 - Mild | 2 - Moderate | 3 - Severe
Hypo-Symptoms
Lumps in breasts *
More tired & sluggish than normal *
Drier hair & skin than normal *
Sleep more than usual *
Weaker muscles *
Colder than others *
Muscle cramps more than usual *
Poorer memory *
More depressed *
Slower thinking *
Eyes are more puffy *
Math is more difficult *
Hoarse or deeper voice *
Constipated more often *
Coarser hair *
Puffy hands or feet *
Unsteady when walking *
Gain weight easily *
Outer third of eyebrows thin *

Next three symptoms are for menstruating females.

If this does not apply to you then all zeros.
Lumpy/fibrous breasts *
Menses more irregular *
Heavier menses *
Hyper-Symptoms
Tachycardia *
Palpitations (skipping of heart) *
Insomnia (can't sleep well) *
Tremors (shaking) *
Increased sweating *
Brittle nails *
Loss of appetite *

By checking this box, I certify that I have read and understand the statements above and take full responsibility for my personal health and well-being.

I agree with the above terms and conditions
Name

First Name Last Name
Date

Month Day Year Date Picker Icon
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

	YES	NO
1. Do you wear a pace maker?
2. Do you have a battery operated or electronic implant?
3. Are taking blood pressure medication?
4. Are you taking seizure medication?
5. Are you taking depression medication?
6. Are you taking medication to maintain blood levels?
7. Are you pregnant?
8. Are you lactating or nursing?
9. Do you have open wounds or sores on your feet?
10. Have you received an organ transplant?
11. Are you prone to psychotic episodes?

General Medical Information

Previously Diagnosed Conditions

Acidosis / Chemical-Heavy Metal Toxicity Assessment

Thyroid Symptom Survey

Urgent Medical Information