HTMA Intake Form

HTMA Client Intake Form

First name

Last name

Address

Age

Occupation

Is this your first HTMA?

If you have previous tests, what is the your test number from your most recent HTMA + name of the lab?

What is your medical history?

Current medications + supplements?

What are your main health concerns or conditions?

this can also include chronic infections, cravings or addictions, anxiety, sleep, emotional states, etc.

What are you hoping to gain by working together?

Share as much or as little as you'd like!

Are you on or were you ever on hormonal or IUD birth control? If so, when?

Are you pregnant or within 1 year postpartum?

Yes

Do you have children? If so, how old?

What is a typical breakfast like for you? Try to give a few days worth of examples

What is a typical lunch like for you? Try to give a few days worth of examples

What is a typical dinner like for you? Try to give a few days worth of examples

What are your bowel movements like? How often, shape, size etc.

What do you have for drink(s) each day?

List illnesses in your immediate family (e.g., thyroid, heart disease, cancer, diabetes, arthritis).

What kind of movement/exercise do you do and how often?

Describe your sleep- Do you have a consistent sleep schedule? how many hours per night and what is the quality of sleep each night?

Do you use any tobacco, cannabis, alcohol, or other substances? If so, how often?

Is there anything else you would like me to know?

I understand that Mineral-Nutritional Balancing is a means to reduce stress and balance body chemistry and that this does not diagnose, treat, or substitute for following the advice of a medical doctor.