HTMA Intake Form

HTMA Initial Form

If you have booked an appointment for HTMA Services, please submit this form in its entirety.

First Name (required)

Last Name (required)

Email (required)

Phone (required)

DOB (required)

Address

Country

Address Line 1 (required)

Address Line 2

City (required)

Province (required)

Postal Code (required)

Gender (required)

Female Male For a Female Child under 18 For a Male Child under 18

Status (required)

Height and Weight (required)

3 Main Health Concerns (required)

Occupation (required)

Typical Tasks, (any Chemical Exposure?) (required)

Additional Symptoms (required) Health Concerns, Diagnoses, etc

When did they start? (required) When symptoms first appeared, and was there any emotional stress happening? (Job change, divorce, childbirth, losses, accidents, trauma)

What have you tried? (required) Medications, therapies, supplements — have they helped?

Current Stress Level (required)

Minimal Some Stress Moderate Stress Significant Stress Chronic Long Standing Stress

Foods you Dislike and/or Exclude (required)

Foods that you eat a lot of (required)

Where do you typically get your food (required)

Meals per day / Snacks / How often / Time frame (required)

Oral Health (required)

Water Intake Daily and what type of water (required)

# Caffeinated Beverages (250ml) a day (required) Just insert approx #

Smoker

Non-smoker Occasional 1-2 cigarettes daily 3-5 cigarettes daily More than 5 cigarettes or other daily Cigars pipe chewing tobacco Quit recently Quit over 5 years ago

Alcohol use or recreational non-prescribed drug use (required)

Prescription Meds taking (required)

Over-the-Counter Medications (required)

Natural Health Supplements (required)

Adverse reactions (required)

Typical Sleep Pattern (required)

Exercise (required)

Vaccinations (required)

Family Health History (required)

Emotional Mental Health (required)

Supplement type preference (required)

Motivation to change (scale 1–10) (required) 1 = won't make dietary changes, won't take supplements. 10 = willing to try what it takes, dietary changes, supplements, understand healing may take time.

General Symptoms

Brain Fog (required) Difficulty with cognition

Fatigue (required)

Difficulty Falling Asleep (required)

Difficulty staying asleep at night (required)

Body Odour (required)

Unable to lose weight (required)

Unable to Gain Weight (required)

Sudden/Unplanned Weightloss (required)

Sleepy or nap during the day (required)

Head, Eyes, Ears

Headaches (required)

Migraines (required)

Dizziness (required)

Vertigo (spinning of room / losing balance) (required)

Faintness (required)

Bloodshot Eyes (required)

Eye Twitches (required)

Dark Circles under Eyes (required)

Vision Problems (required)

Cataracts (required)

Macular Degeneration (required)

Night Blindness (required)

Tinnitus (ringing in the ears) (required)

Ear Infections/Ear Aches (required)

Skin, Hair, Nails

Acne (required)

Dermatitis (required)

Eczema (required)

Psoriasis (required)

Rosacea (required)

Hives (required)

Rash (required)

Itching (required)

Vitiligo (required)

Dry Skin (required)

Nail Appearance (required)

Brittle Nails Soft Nails Pliable Peel Ridges Vertical Separation from Nail Bed Yellowish Splitting Nails No Issues

Hair Health (required)

Thinning Hair Brittle breaks easily Early greying Hair Shedding Balding Dandruff No Issues

Joints, Muscles, Nerves

Arthritis (Osteo) (required)

Arthritis (Rheumatoid) (required)

Fractures (required)

Bone Spurs (required)

Gout (required)

Bursitis (required)

Joint Pain (required)

Joint Swelling or Redness (required)

Joint Stiffness (required)

Osteopenia (required)

Osteoporosis (required)

TMJ problems (required)

Tendonitis (required)

Muscle Pain or Stiffness (required)

Muscle Weakness (required)

Tremors (required)

Balance/Coordination Problems (required)

Restless Legs (required)

Carpal Tunnel Syndrome (required)

Sciatica (required)

Were your Injuries (required)

Muscle Cramps — location (check all that apply)

Calf Foot Leg Back

Muscle Cramps (required)

Numbness or Tingling (required) Pins and needles feeling

Nose, Mouth, Teeth

Stuffy Nose (required)

Sinusitis (required)

Sinus Infections (required)

Halitosis (required)

Cracks in corner of mouth (required)

White Coating on Tongue (required)

Canker sores (required)

Cold Sores (required)

Dry Mouth (required)

Digestion & Elimination

Abdominal Pain (required)

Bloating after Meals (required)

Flatulence (gas) (required)

Feel full after eating small amounts of food (required)

Belching/Burping (required)

Foul Smelling Gas or Stool (required)

Heartburn (required)

GERD/Acid Reflux (required)

Nausea/Vomiting (required)

Stomach Ulcers (required)

Diarrhea (required)

Constipation (required)

Hemorrhoids (required)

Blood or Mucus in Stool (required)

Undigested Food in Stool (required)

Anal Itching (required)

IBS (Irritable Bowel Syndrome) (required)

IBD (Inflammatory Bowel Disease) (required)

Crohn's Disease (required)

Urinary

Bladder/Urinary Infections (required)

Pain/Burning during Urination (required)

Cystitis (Interstitial) (required)

Frequent Urination (required)

Night time Urination (required)

Incontinence (required)

Urgency (required)

Bed Wetting (required)

Rarely feel the Urge to Urinate (required)

Kidney Stones (required)

Cardiovascular

Arrhythmia (required)

Heart Palpitations (required)

Heart Murmur (required)

Tachycardia (required)

Respiratory

Bronchitis (required)

Pneumonia (required)

Cough - Dry (required)

Cough - Productive (required)

Wheezing (required)

Asthma (required)

Shortness of Breath (required)

Snoring (required)

Sleep Apnea (required)

Mood, Mind & Emotions

ADD/ADHD (required)

Autism (required)

Learning Disabilities (required)

Anxiety (required)

Panic Attacks (required)

Fearfulness (required)

Irritability/Easily Angered (required)

Anger Episodes (required)

Mood Swings (required)

Easily Upset (required)

Feel highly stressed (Life/Work) (required)

Depression (required)

Suicidal Thoughts (required)

Bipolar Disorder (required)

Manic Depressive Disorder (required)

Schizophrenia (required)

Hallucinations (required)

Phobias (required)

Nightmares (required)

Have had violent/traumatic life experiences (required)

Impulsive Behaviour (required)

Difficulty Concentrating (required)

Poor Memory (required)

OCD or Obsessive Thoughts (required)

Male Hormonal/Reproductive

Required toggle is off, but if Male, this is mandatory to fill in.

Benign Prostatic Hyperplasia

Impotency

Infertile

Low Libido

Have you ever taken Hormone Replacement Therapy

HRT — Male What type, dosage and duration. If none, type N/A

Female Hormonal/Reproductive

Required toggle is off, but if Female, this is mandatory to fill in.

Amenorrhea (no period)

Dysmenorrhea (painful period)

Menorrhagia (heavy period)

Irregular Periods

PMS

Have you used Birth Control

Endometriosis

Breast Cysts or Lumps

Ovarian Cysts

PCOS

Infertility

Low Libido

Hot Flashes/Night Sweats

Perimenopausal

Menopause

Have you ever taken Hormone Replacement Therapy

Birth Control Type, duration and how long ago

HRT — Female What type, dosage, duration, how long ago

Post Menopause (required)

Vaginal Discharge

Diseases Diagnosed

Alcoholism (required)

Glaucoma (required)

Alzheimer's Disease (required)

Anemia (required)

Bell's Palsy (required)

Cancer (required)

Chronic Fatigue Syndrome (required)

Celiac Disease (required)

Cirrhosis (required)

Congestive Heart Failure (required)

Coronary Heart Disease (required)

Diabetes Type 1 (required)

Diabetes Type 2 (required)

Diverticulitis/Diverticulosis (required)

Emphysema (required)

Epilepsy/Seizures (required)

Fibromyalgia (required)

Gall Stones (required)

Heart Attack (required)

Heavy Metal Toxicity (required)

Hypothyroidism (required)

Hyperthyroidism (required)

Goiter (required)

Grave's Disease (required)

Hashimoto's (required)

Hemochromatosis (required)

Hepatitis (required)

Hiatal Hernia (required)

Leukemia (required)

Liver Disease (required)

Lupus (required)

Melanoma (required)

Meniere's Disease (required)

Multiple Sclerosis (required)

Muscular Dystrophy (required)

Pancreatitis (required)

Parkinson's Disease (required)

Stroke (required)

Tuberculosis (required)

Scleroderma

Surgical

Appendectomy (required)

Gall Bladder Removal (required)

Hernia (required)

Hysterectomy (required)

Tonsillectomy (required)

Other Surgery (required) What and approximately how long ago, or type N/A

Infections

Travel Outside of Canada/USA (required)

Chicken Pox (required)

Shingles (required)

Herpes (required)

Cytomegalovirus (required)

Epstein Barr Virus (Mononucleosis) (required)

Yeast/Fungal Infections (required)

Parasites/amoebas (required)

Montezuma's Revenge (required)

Bacterial (required)

H. Pylori (required)

Lyme Disease (required)

Type of Bacterial Infection (required) What and how long ago? If none, type N/A

Food Issues

Appetite - Excessive (required)

Appetite - Reduced (required)

Thirst - Excessive (required)

Hypoglycemia (low blood sugar) (required)

Hyperglycemia (high blood sugar) (required)

Difficulty digesting Fats (required)

Difficulty with Spicy Foods (required)

Sugar Cravings (required)

Salt Cravings (required)

Eating Disorder (required)

Gluten Sensitivity (required)

Dairy Sensitivity or Allergy (required)

Lactose Intolerance (required)

Egg Sensitivity or Allergy (required)

Soy Sensitivity or Allergy (required)

Corn Sensitivity or Allergy (required)

Nightshade Sensitivity (required)

Carbohydrate Sensitivity (required)

Multiple Food Sensitivity (required)

Environmental

Live/Work in a place with visible mold (required)

Live/Work in a place with a musty smell (required)

Live/Work in a place with previous flood damage (required)

Live/Work in an old building (required)

Do you use a dehumidifier (required)

Do you use plug-in air fresheners (required)

Do you wear perfume/aftershave (required)

Do you have pets (required)

Diet

Gluten-Free (required)

Dairy-Free (required)

Egg-Free (required)

Nightshade-Free (required)

Soy-Free (required)

Vegetarian (required)

Vegan (required)

Raw Food (required)

Ketogenic (required)

Paleo (required)

Low-Fat (required)

Low Sodium (required)

Intermittent Fasting (required)

Sugar-Free (required) Avoid processed sugar, but eat fruits

Type of Appointment preferred (required)

Other Information Anything you may think pertinent to inform me for this health inquiry