INTAKE FORM / TOXICITY QUESTIONNAIRE

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
  • 1 - Occasionally have it, effect is not severe
  • 2 - Occasionally have it, effect is severe
  • 3 - Frequently have it, effect is not severe
  • 4 - frequently have it, effect is severe

SYMPTOM QUESTIONNAIRE (SQ)

Head

Eyes

Ears

Nose

Mouth/Throat

Skin

Lungs

Emotions

G.I. Tract

Joints/Muscles

Heart/Vascular

Weight

Energy/Activity

Mind

Infection

Other

CHEMICAL TOLERABILITY TEST (CTT)

1. Are you currently using prescription drugs?

  • If yes, how many are you currently taking?

2. Are you presently taking one or more of the following over-the-counter drugs?

3. If you have used or currently use prescription drugs, which of the following scenarios best describes your response to them:

4. Do you currently use or within the last six months had you regularly used tobacco products?

5. Do you have strong negative reactions to caffeine or caffeine containing products?

6. Do you commonly experience “brain fog,” fatigue, or drowsiness?

7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?

8. Do you feel ill after you consume even a small amount of wine?

9. Do you have a personal history of...

10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or chemical solvents?

11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar, and vegetables?

OVERALL SCORE

  • Symptom Questionnaire Score (SQ)
  • Chemical Tolerability Test Score (CTT)

KEY: UNDERSTANDING YOUR SCORE

SQ SCORE CTT SCORE PLAN OF ACTION
50 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

TOXINS ARE EVERYWHERE!

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-ONS

CHOOSE YOUR PROGRAM TODAY AND START YOUR DETOX & REJUVENATION LIFESTYLE!

CLIENT INFORMATION ~ CLUB HEAL CIRCUIT

  • Phone
  • Text
  • Voicemail
  • Email
  • All
  • Social Media
  • Website
  • Yelp
  • Press
  • Google
  • Friend:
  • Referring Physician:
  • For what condition/diagnosis:
  • Pregnant
  • Pacemaker
  • Epilepsy
  • Spinal Fusions
  • Cancer Diagnosis
  • Serious Medical Condition
  • Blood clots
  • Issues with sweating/or increasing heart rate
  • Issues with Bowel Elimination:
  • /Day or /Week
  • Juice
  • Fasting
  • Supplement Cleanse
  • Detox retreat
  • Cleanse Program
  • Other:
  • Yes No
  • Yes No

CLIENT INFORMATION ~ PRIVATE ROOM ADD-ONS/FAT MELTING/SKIN CARE

  • Yes No
  • Describe:
  • What kind of results did you get?
  • Yes No
  • What kind of results did you get?
  • (both of these will impede your fat melting results)
  • Yes No
  • What kind of results did you get?
  • Yes No
  • Why?
  • Yes No
  • Yes No
  • Yes No
  • Please Explain:
  • or sensitive to essential oils, collagen, stem cells, or hyaluronic acid?
  • Edema
  • Post Surgical Swelling
  • Cellulite
  • Lactic Acid Build Up
  • Poor Circulation
  • Lymphaedema

TOXIN AWARENESS QUESTIONNAIRE

1. Do you have a household mold problem?

  • Yes
  • No

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

6. Have you ever been tested for toxicity ~ from workplace or home?

  • Yes
  • No
  • What symptoms have you experienced:

7. Do you currently use any detoxification modalities, products, or protocols?

TOXIN AWARENESS QUESTIONNAIRE CONTINUED

Please 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

Do you use deodorant that contains aluminum?

  • Yes
  • No

Do you use chemically based make up, hair coloring products and body products?

  • Yes
  • No

Do you use a fluoride based toothpaste?

  • Yes
  • No

Do you drink unfiltered tap water? (vs filtered water)

  • Yes
  • No

Are your supplements purchased from Walgreens, GNC, Rite Aid, Walmart?

  • Yes
  • No

Do you shower with unfiltered tap water? (vs filtered tap water)

  • Yes
  • No

Do you use a Smart Meter on your home?

  • Yes
  • No

Are you being exposed to dangerous EMF frequencies with your cell phone?

  • Yes
  • No

Are you being exposed to dangerous EMF frequencies at your home/work place?

  • Yes
  • No

Do you eat from canned foods often?

  • Yes
  • No

Do you have a chlorinated hot tub/jacuzzi or pool?

  • Yes
  • No

Do you consume conventionally grown (non-organic) fruits and vegetables regularly?

  • Yes
  • No

Do you consume fish, sushi or seafood more than twice a week?

  • Yes
  • No

Do you consume conventionally raised animal products (meat, dairy, eggs) regularly?

  • Yes
  • No

Do you consume fast foods, canned/packaged foods, soda, or foods with artificial colors, flavors,
preservatives or sweeteners more than three times a week?

  • Yes
  • No

Have you lived in a mobile home, boat, or RV, or a very old or brand-new home?

  • Yes
  • No

Have you recently been exposed to new construction materials or furniture
(e.g., paint, laminate flooring, particle board, new carpeting, bedding, furniture, etc.)?

  • Yes
  • No

Does your home or workplace have cracking paint or decaying insulation or foam, visible mold, water damage,
or damp windows, basement, or crawlspaces?

  • Yes
  • No

Are you often exposed to adhesives, paints, flea treatments, varnishes, solvents, welding/soldering materials or
other airborne chemicals at home or work?

  • Yes
  • No

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?

  • Yes
  • No

Do you regularly use conventional cleaning chemicals, disinfectants, hand sanitizers, air fresheners,
scented candles, or other scented products at home or work?

  • Yes
  • No

Have you lived in an agricultural area or often been exposed to herbicides, pesticides, fungicides at home,
work, parks & golf courses, or roadsides?

  • Yes
  • No

Do you live or work in a sealed building with recirculated air or a building that has wood, propane, or gas stoves or appliances?

  • Yes
  • No

Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?

  • Yes
  • No

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?

  • Yes
  • No

Do you smoke or are often exposed to second-hand smoke, fly often, or run or bike to work along busy streets?

  • Yes
  • No

Have you had any unusual reactions to anesthesia or to prescription or over-the-counter medications?

  • Yes
  • No

Have you had root canals, tooth extractions, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays,
braces, mouth guards, dental implants, etc.?

  • Yes
  • No

Do you use a cordless land line phone at work or home?

  • Yes
  • No

TOXIC LOAD ~ BLOCKS & CHALLENGES

  • - PAIN
  • 000 - SURGERIES & WHAT KIND
  • +++ - INJURIES
  • ▲▲▲ - EDEMA/SWELLING
  • XXX - BLOCKED AREAS

CANCELLATION POLICY

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