• Client Health Intake Questionnaire

    Share your health history, goals, and current routine so we can review your HTMA results and build a plan that fits you.

  • Disclaimer

  • Access Disclaimer Template Here [Insert the text from your disclaimer here before sending to a client!]

  • Please check the box to acknowledge consent of each of the following:*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • About You

  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*

  • Your Health Goals

  •
  • Has Stress Been High for a Long Time?

  • Sleep & Energy

  • Do you sleep well?*
  • Do you wake during the night?*
  • Usual bedtime*
  • Usual wake time*
  • Do you often feel tired but wired?*

  • Water, Caffeine & Alcohol

  • Do you add electrolytes, salt, or minerals to your water?*
  • Which caffeinated beverages do you drink?
  • Do you consume caffeine on an empty stomach?

  • Diet

  • What cookware do you use?
  • What fats do you use for cooking?
  • How often do you eat organic foods?
  • Which eating styles best describe you?
  • Do you regularly skip meals or go long periods without eating?
  • Do you add salt to your food?
  • Do you crave salt?
  • Do you crave sweets or need something sweet in the afternoon?

  • Digestion

  • Symptoms after meals*
  • Have you had your gallbladder removed?*
  • Bowel movement frequency*
  • Do you take acid reducers or antacids? Which ones?
  • Have you been diagnosed with any digestive condition? Which ones?

  • Symptoms

  • Which of these do you experience regularly? Choose all that apply.

  • Women's Health (optional section)

  • Which of the following apply to your menstrual cycle?
  • Do you currently use, or have you ever used, hormonal birth control?*
  • Have you ever had a copper IUD?
  • Are you currently on HRT or any hormone therapy?*
  • Which best describes your current pregnancy or postpartum status?

  • Men's Health (optional section)

  • Men, please choose all that apply:

  • Movement

  • Do you sweat a lot during exercise or in daily life?*

  • Supplements & Medications

  • Any supplements or medications started, stopped, or changed in the last 6 months?*
  • Are you currently taking blood pressure medication or a diuretic?*

  • Medical History

  • Are you currently under a doctor or practitioner’s care for a specific health issue?*
  • Which of the following have you been diagnosed with?*
  • Prior to getting pregnant with you, did your mother take birth control or use a copper IUD?
  • Do you have a family history of any of the following?

  • Dental

  • Do you have silver (amalgam) fillings?*
  • Do you grind or clench your teeth?*
  • Do you have any of the following?

  • Home & Environment

  • Do you live in a place with hard water?*
  • Do you use a water softener?
  • If you have a well, when was it last tested?
     - -
    2 digit month, 2 digit day, 4 digit year
  • What stains or buildup do you see in sinks, tub, or toilet?
  • Is your home near any of the following?
  • Do you have older pressure-treated wood at home, such as decks or playsets from before 2004?
  • Do any of the following apply?

  • Hair

  • Have you noticed significant hair loss or shedding?
  • Should be Empty: