HTMA INTAKE FORM Name * First Name Last Name Email * Date of Birth * MM DD YYYY Gender * Male Female Other Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Occupation * Height * Weight * How were you referred? * What are your main health concerns or conditions? * Please list any medications or food supplements you are currently taking: * Please list any recent medical tests results you have, such as blood tests: * Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis. * What are examples of typical breakfasts for you? Beverages? * What are your Mid-morning Snacks if any? * What are typical lunches for you? Beverages? * What are your Mid-afternoon Snacks if any? * What are typical dinners for you? Beverages? * What are your Evening Snacks if any? * How often do you exercise? * Never Once a week Two to Three times a week Three to Five times a week Five+ times a week What type of exercise(s)? * About how many hours of sleep do you get per day? * 0-3 hours a night 3-6 hours a night 6-8 hours a night 8+ hours a night SYMPTOMS: Please checkmark any conditions or symptoms that presently describe you and are most important to you. * Acne Alcoholism Allergies Anger Angina Anemia Anxiety Arteriosclerosis Arthritis Asthma Attention Deficit Autism Bladder Infections Bipolar Disorder Bloating Brain Fog Bronchitis Bursitis Caffeine sensitivity Cancer Cataracts Cirrhosis Colitis Confusion Constipation Cough Cramps Delayed Development Depression Diabetes Diarrhea Diverticulitis Drug Addiction Dyslexia Easy Bruising Eczema Emphysema Excessive Plaque on Teeth Fat Cravings Fatigue Fibroid Tumors Fibrocystic Breasts Fissures Frequent Urination Fungal Infections/Candida Gall Stones Glaucoma Gout Gum Disease Hair Loss Heart Attack Heart Palpitations Heartburn Heavy periods Hemorrhoids High Blood Pressure High Cholesterol High Triglycerides Hives Hot Flashes Hyperkinesis Hypoglycemia Hypothyroidism Impotence Infections/Viruses Infertility Irritability Irritable before meals Joint Pain Joint Stiffness Kidney Infections Kidney Stones Learning Disability Light/Irregular Periods Low Blood pressure Low Body Temperature Lyme Disease Meniere's disease Menopause Mind Races Mood Swings Multiple Sclerosis Muscle Cramps Muscle Weakness No hunger No Menstruation Obsessive/Compulsive Osteo Arthritis Osteoporosis Other Food Cravings Ovarian Cysts Panic Attacks Parkinson's Disease Post-nasal Drip Poor Circulation Poor Memory Premenstrual Syndrome Prostate Problems Psoriasis Rapid Heart Rate Rheumatoid Muscle Pain Schizophrenia Seizures Scleroderma Sinus Congestion Sinus Headaches Skipping Heart Beats Slow Wound Healing Smoking Stomach Pain Sugar Reactions Sweet Cravings Tend to Gain Weight Tend to Lose Weight Tension Headaches Tooth Decay Tumors/Cancer Trouble Sleeping Ulcer Water Retention Yeast infections Other Symptoms (please list) CLIENT WAIVER AGREEMENT * By clicking the box and typing my name below, I agree to the terms of the waiver as outlined here: 1. I understand that Nicole Pattison is certified as a Mineral Balancing Practitioner, but is not a medical doctor 2. I understand Nicole Pattison does not practice medicine or provide medical diagnosis, care, or treatment. The education provided by Nicole is for improving health through body cleansing and maintaining superior health through quality nutritional and lifestyle practices. 3. I understand that nutrition is not an exact science. I acknowledge that no claims or guarantees have been made to me regarding my health as a result of my using the disciplines taught by Nicole Pattison at The Healing Room. 4. I accept full responsibility for applying advice I obtain from Nicole Pattison at the Healing Room 5. I understand Nicole Pattison is not permitted to render medical opinions, diagnose illness or prescribe medical treatment. 6. I understand that mineral balancing is a means to reduce stress and balance body chemistry. It is not intended as a diagnosis, treatment or prescription for any condition or disease. I have read and understand the foregoing waiver. As a client, I recognize that nutrition is a foundation to achieving better health and Nicole's services are one of the modalities available to help support my body nutritionally. Nicole's purpose is to provide clients with progressive health based on their individual nutritional needs. She uses a whole-body approach that includes food guidelines, nutrient supplements, detoxification protocols, and lifestyle improvements that are based on your Hair Tissue Mineral Analysis (HTMA) results. I AGREE I do not agree Please type out your name * Please enter todays date * MM DD YYYY Thank you for filing out the HTMA Intake form. We will be in contact with you shortly!