INTAKE FORMComplete this intake form to receive your Hair Tissue Mineral Analysis (HTMA) Test in the mail. Name * First Name Last Name Email * Mailing Address (for test kit) * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (for FedEx) * (###) ### #### What are your primary health concerns or goals for HTMA testing? (E.g., fatigue, mood swings, hair loss, weight issues, digestion problems, etc.) Have you been diagnosed with any medical conditions? (Please list any current or past diagnoses) List any medications or supplements you are currently taking: Do you have any known allergies or food limitations? Do you have any known allergies or food limitations? Check each of the following that you experience: Fatigue or low energy levels Anxiety, depression, or mood swings Difficulty sleeping Hair loss or thinning Digestive issues (e.g., bloating, constipation) Difficulty losing or gaining weight Sensitivity to heat or cold How would you rate your average stress levels? (1 is extremely low, 10 is extremely high) 1 2 3 4 5 6 7 8 9 10 Have you experienced any significant emotional events (e.g., loss, trauma) in the past year? Is there anything else about your health that you would like to share? Thank you!
