HTMA Re-test Questionnaire
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2 digit month, 2 digit day, 4 digit year
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Name
First Name
Last Name
What are the biggest changes you have seen through our work together so far?
Do you have any new or existing health concerns that you would like to focus on?
Since your previous HTMA test, what changes have you made to your diet?
Since your previous HTMA test, what changes have been made to your sleep, exercise, or stress-levels?
Which option best describes how you have taken the recommended supplements?
I've been taking them daily and it has become part of my routine.
I take them most days.
I'm lucky if I remember to take them a couple times a week.
I did not have any supplements in my protocol.
I haven't been taking them.
Other
Which option best describes how you feel about the supplements? (Check all that apply!)
I feel a huge difference from taking them!
I think they are making a difference, but it isn't drastic.
This is too many supplements; I would prefer to take fewer.
I wouldn't mind taking an additional supplement or two, if it is recommended based on my re-test results.
I'm feeling great and I'd like to discuss a maintenance protocol.
Other
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Overall, how likely are you to recommend working with me to friends and family?
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If you have any other feedback, please share it here. Continuous improvement is very important to me and I appreciate all constructive criticism. This will be kept confidential.
I am incredibly grateful for personal testimonials - Here is a spot to write a few sentences if you feel inclined! Please note: I'll never share your full name, but please let me know if you'd like me to keep your first name and last initial anonymous.
Would you like to refer a friend or family member? Referrals are the greatest compliment and the heart of my business. They will receive a discount on any service they choose!
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