Initial 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!

Name
Your Name
Email
Type in your email address, then you will need to confirm your email address again.
Address
Your physical address
Your phone number area code first. If you are out of the US, please enter your country code.
Use month/day/year format
your age
Your weight in pounds. If you use Kilograms, please note that.
Feet plus inches.
Gender
Are you female or male?
If you are retired, please state that. Otherwise, state what your occupation is.
I always like to know my referral sources so I can thank them.
Consent
By clicking this box, I understand the terms and conditions that are 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.

Tell Me About Your Concerns

Please list what your main health concerns or conditions are.
Tell me relevant information as relates to your health history, starting from when you remember feelling pretty well. Include vaccinations, illness, trauma, or maybe an occupational exposure.
You can upload files later in this document if you prefer.
Include any recent test results that were flagged high or low. NOTE: You can upload your test results later on if you prefer.
List major conditions in parents, siblings, or children.
Describe your usual activities, such as walking, yoga, or gardening.
Estimate your average hours and note if sleep feels restful.
Have you found any therapies, diets, supplements, medications helpful? If so, list them.
What therapies, diets, supplements, medications have NOT worked for you in the past?

Diet

Proteins, Vegetables (if any), Grains (if any) and Beverages
Fruit? Popcorn? Chips? Nothing?
Proteins, Vegetables (if any), Grains (if any) and Beverages
Fruit? Popcorn? Chips? Nothing?
Proteins, Vegetables (if any), Grains (if any) and Beverages
Fruit? Popcorn? Chips? Nothing?

Health Issues & Life Experiences Questionnaire

Use the Tab key to move through options and the Spacebar to check or uncheck boxes.
Conditions/Symptoms (select all that apply)
Male
If you have any unique male issues, check a box. If you do not have issues, click Not applicable using the space bar.
Female
If you have any unique female issues, check a box. If you do not have issues, click Not applicable using the space bar.
Trauma
If you have any issues in this area, use space bar to check the box.
Drag & Drop Files, Choose Files 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.
If you have any additional comments, please put them here.

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.

My work draws on both my clinical training as a licensed Occupational Therapist (OT/L, 30 years) and my personal study of intuitive, energy-based wellness practices. I'm always clear about which informs which, so you know what you're receiving.