Name
Surname
Email
Gender
Age
Weight
Occupation
Pregnant?
Breastfeeding/Lactating?
Do you have children? If so, what are their ages and were any of the births C-sections?
What is your biggest complaint, symptoms or concerns with your health?
Any Dental fillings (amalgams?), root canals, implants?
Do you currently have a cycle and what is your typical cycle like (if female)? E.g. How many days is your full cycle? How long does menstruation last? Any specific symptoms you can name? Heavy, painful, clotted? Colour dark or bright? Is your cycle regular? Do you experience worsening of symptoms around period/ovulation? Do you know if you ovulate?
Do you get PMS? If so, what are your symptoms?
What supplements do you currently use? Please name brands if possible.
Do you use any medications?
Have you done any other diagnostic testing (Blood, Urine, Oat, GI-tests, HTMA, DUTCH etc?
Have you tested for infections, Lyme, Epstein Barr Virus, Mold Toxicity or anything similar?
Do you have a history of antibiotic use? Confirmed or suspected vaccine injury? Or any other reactions or medications or hormonal birth control?
Birth Control used and for how long?
Have you had any vaccinations? Please elaborate
Any surgeries like breast implants/explant, gallbladder removal, thyroid removal?
What is your typical diet like? Do you eat Breakfast? Do you have a good appetite? How often do you eat during the day?
How is your digestion generally (bloating, water retention, at least 1x bowel movement per day, food sensitivities & intolerances or allergies, weight remain stable)?
Do you experience any cravings like sugar, salt, protein, fat or chocolate?
Do you smoke and consume any alcohol, if so, how often?
What are your levels of motivation and creativity?
Do you have any mental or emotional problems/stress or trauma? (happy, sad, fears, worries, anxiety, depression, anger, guilt, apathy, irritable, mood swings, nervous)
How is your energy level? Is it stable, do you feel energised upon waking up, does your energy dip/improve during the day? Do you experience fatigue?
Do you ever experience blood-sugar dips or feel jittery?
Are you content and feel resilient to life's stressors?
How is your concentration? How is your long/short-term memory?
Is there any blood, mucous in your stools? What is the color? What is the shape? Float or sink? Loose or Compact?
What is the color and odour of your urine?
Do you suffer from any aches or pains, where, how often?
What do you hope to get out of working together?
Please confirm with a ‘Y’ below that you understand that the suggestions made from the above information provided and any HTMA testing done is absolutely NOT to be taken as medical advice. We recommend you always talk to your healthcare professional before trying a new health supplement regimen or diet. If requested that Natural Origins review my hair mineral analysis report(s) (obtained from Analytical Research Labs in Phoenix or Trace Elements, Inc. located in Addison, TX) and design a nutritional balancing program for me, it is for the purpose of aiding in the re‐balancing of the body’s minerals, reducing stress and enhancing energy. I understand that Nutritional Counselling is not intended as diagnosis, prescribe, treat or cure for any disease or health condition, mental or physical, real or imaginary. It is also not intended as a substitute for regular medical care and that I am encouraged to seek medical support from a primary medical care provider and that any nutritional balancing information offered is considered as general information only. I understand that under no circumstances should any medication be discontinued without first consulting the prescribing medical provider. I understand that the nutritional information offered is also not intended as a substitute for regular medical care and that I am encouraged to see my medical care provider for diagnosis and treatment of any medical concerns I may have, and before implementing any diet, supplement, exercise or other lifestyle change. I also understand that Nutritional Counselling is to be used at my own risk. I understand that if I enter the Nutritional Program, that I am strongly encouraged to perform a mineral hair analysis re‐test in 3‐4months to determine if the suggested program needs to be modified as the mineral patterns change while it balances. All information provided by the client (you) is kept strictly confidential in accordance with all applicable laws. None of your information will ever be shared or discussed with any third party without your express written permission.
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