Getting started:
Step 1: Hover your mouse over the [Systems] menu → click on the [Wellness Score®] → [Resources] → [Forms].
Step 2: A pop-up window will load displaying a list of all the forms we have available that correspond with our different parameters. Click on any of the linked forms and they will either load as a PDF or a Word Doc download:
The Wellness Score® Consultation & Exam Form: This form directly correlates with the training video from Dr. Dane Donohue. Click HERE to watch this
Standard Process Systems Survey: The Standard Process form relates to the parameter by the same name
Health Satisfaction Score (HSQ): This allows the patient to score their health based on 3 categories. The grand total of all sections is entered into the Wellness Report:
Physical Health
Emotional/Mental Health
Chemical/Nutritional Health
Function Rating Index (FRI): This form is filled out by the patient to rate their pain in 7 different areas, and the total score is entered into the Wellness Report for the parameter by the same name.
Pain Intensity
Sleeping
Personal Care (washing, dressing, etc.)
Travel (driving, etc.)
Work
Recreation
Frequency of Pain
Lifting
Walking
Standing
Medical Symptoms Questionnaire (MSQ): This allows the patient to list the frequency of symptoms occurring in 15 different areas of the body. The point scale ranges from 0-4. 0 = Never or almost never have the symptom and 4 - Frequently have it, the effect is severe
Xenobiotic Tolerability Test (XTT): This form is filled out by the patient and first lists the same questions from the Medical Symptoms Questionaire (MSQ) as above. The Xenobiotic Tolerability questions then dive into asking about current prescription drug use for the patient and are then totaled along with the MSQ section by the Provider. The Xenobiotic grand total is the score that will be added to your Wellness Report. The ideal range is 0-8 which would be a low to moderate rating.
McLaughlin Health Risk Assessment: The McGlaughlin Health Risk Assessment along with your other exam findings, will help determine the cause of health issues and mainly focuses on inflammation. The form consists of 20 questions with a choice of a, b, c, d, & e for answers.
Add the number of a. answers and multiply by 5
Add the number of b. answers and multiply by 4
Add the number of c. answers and multiply by 3
Add the number of d. answers and multiply by 2
Add the number of e. answers and multiply by 1
The RAND SF-36 & Oswestry Disability Index are copyright-protected forms. Therefore, we cannot provide free downloads for them. However, you can Google them and find where you can legally get them.
