Intake Form

Please complete all spaces

    What are your 3 top health concerns?:

    Please list your three main focus areas for your health, first will be considered your main focus unless otherwise noted.

    Your name:

    Age:

    Gender:

    What is your current marital status?:

    Your email:

    Do you have any kids at home or who you still support in an ongoing way? Do you care for anyone in your extended family? EG parents, sibling, etc…

    Please feel free to share anything that seems relevant - if they require support or health care, or you often focus on them more than your own health, or in general if there’s anything related to your kids which impacts on you and/or your health. If you have already covered details previously, you do not need to repeat them here.

    Any other concerns you have with your current living condition?

    Please state each option that applies.

    Please state all options that apply to your occupation / employment situation:

    Food and dietary related:

    In this section we want to get some insight into your food choices.

    Digestion

    Please summarise any digestive issues you have including when they have started and what you have done to remedy them. If you have already covered details previously, you do not need to repeat them here.

    I usually use the following oils when I cook (state the numbers that apply):

    Please state each option that applies.

    Other:

    On average, how many servings of “fresh” food do you eat per day (fruit, vegetables, green foods, etc)?

    What are some of your favourite healthy foods?

    Do you have any food allergies or intolerances?

    Are you a vegetarian and/or vegan, or have you been in the past or are you following any specific diet? How long for?

    How much of your diet is organic food?

    Toxic Load

    Do you follow a clean lifestyle and avoid or limit exposure in your personal health care products etc. Do you use aluminium free deodorant? Do you use a chlorine filter in your drinking or shower water?

    Detoxification

    What have you done in the past or are currently doing to detoxify your body? Saunas/enemas/castor oil packs/dry skin brushing/etc.

    Stress and symptom history:

    Let’s understand your family history, childhood, teenage and beyond health and stress history

    Mothers health history:

    Please share your mother’s birthplace and year born, number or pregnancies and births she had, and where you are in the birth order. As best as you can, summarise her health history, including pregnancy experience, traumatic events, etc.

    Fathers health history:

    Please share your fathers birthplace and year born. As best as you can summarise his health history, including traumatic events, etc.

    How would you rate your childhood in terms of stress, sickness? Were you sick a lot? Lots of stress in your home life?

    1 being sick a lot, stressed - 5 being not sick much, not much stress

    Childhood history:

    Where were you born? Were there any stressful events happening in your mother’s life before or while she was pregnant with you? Did you have any sicknesses you regularly experienced or that stand out in your memories? Did you move a lot? How was school? As best as you can summarise your health history, including traumatic or stressful events, etc.

    Teenage history:

    Were there any significant changes as you transitioned into teenage years? Were there any stressful events happening in your teenage years? Did you have any sicknesses you regularly experienced or that stand out in your memories? As best as you can summarise your health history, including traumatic or stressful events, etc.

    Rate how you feel about your childhood overall:

    1 being unhappy not positive - 10 being content, happy positive

    Early adult health history:

    What are the significant events that stand out in your mind? As you gained independence, did you experience any sicknesses or symptoms/conditions get worse from your childhood/teenage years? Are there any other non-health related events that stand out in your memories? As best as you can, summarise your health history, including traumatic or stressful events, etc.

    Adult health history:

    What are the significant events that stand out in your mind? When did significant symptoms start? Did you have any sicknesses from your earlier years start to amplify now or suddenly appear? Are there any non-health related events that stand out in your memories? As best as you can summarise your health history, including traumatic or stressful events, etc.

    General health history:

    Please share any relevant history about consuming alcohol, drug use, smoking, etc.

    Please share any relevant details and history. If you have already covered details previously, you do not need to repeat them here.

    Do you have any regular digestive complaints such as constipation, diarrhoea, bloating, reflux?

    Please share any relevant details and history. If you have already covered details previously you do not need to repeat them here.

    Do you have a history of dental work including root canals, silver fillings/amalgams, etc?

    Please share any relevant details and history. If you have already covered details previously you do not need to repeat them here.

    Have you in the past, or presently experienced any of the following conditions/events including (but not limited to) heart failure and/or attack, seizures, pacemaker, high cholesterol, surgeries, stroke, Parkinson’s or Alzheimer’s disease, diabetes, organ transplant etc?

    Please share any relevant details and history. If you have already covered details previously you do not need to repeat them here.

    If you are a female, do you have any female-only conditions you have dealt with, or currently deal with? EG endometriosis, PCOS, Hormone imbalances etc.

    Please share any relevant details and history. If you have already covered details previously you do not need to repeat them here.

    If you are a female, are you pregnant or breastfeeding now, have been pregnant in the past or plan to get pregnant soon?

    Please share general information about the age of children, any difficulties you had with their pregnancies or deliveries and/or after they arrived. If you have gone through pregnancy losses, please share what you feel comfortable with (even if that’s just that you had a miscarriage/or ectopic pregnancy, later pregnancy loss etc) if you have already covered details previously, you do not need to repeat them here.

    If you are a male, do you have any male-only conditions you have dealt with, or currently deal with? EG prostate problems, impotence, erectile dysfunction, bladder irritation, frequent urination, etc.

    Please share any relevant details and history. If you have already covered details previously, you do not need to repeat them here.

    Exercise

    Are you able to move your body without pain and if so, what do you practice?

    Support

    Do you have a support network who understands your health concerns and supports you in your time of need?

    Loving and nurturing yourself

    What do you do to love and nurture yourself?

    Sleep status:

    Tell me about your sleep

    Do you get enough sleep? Do you wake feeling rested? Is your sleep restless or interrupted by frequent waking?

    Please share any relevant details and history.

    Overall, how do you rate the quality of your sleep?

    1 being poor - 10 being Amazing

    What are your habits around sleep and device use/healthy sleep habits?

    This includes how you would wind down before sleep, waking up in the morning or during the night. (Please state each option that applies)

    Supplement and protocol history

    I would like to learn about what you have done in the past and where you are at now with supplements and medications and Root Cause Protocol…

    Previous Protocols

    Please give me a summary of any past protocols and types of practitioners you have seen in your quest for health. How did you feel during these protocols? What worked and what didn’t? If you have already covered details previously, you do not need to repeat them here.

    Have you started any of the Root Cause Protocol STARTS? If so, which steps?

    Are you currently taking any prescription or over the counter medications?

    If yes please list these

    Have you had any immunisations/vaccinations during the last 5 years and if so when?

    Are you currently taking any dietary supplements?

    If yes please list these

    Have you used, any of the items found in The Root Cause Protocol list of STOPS? If so, please list which ones.

    Any of the following: Iron, Vitamin D3, Calcium, Zinc, Molybdenum, “Drugstore” once a day, Prenatal’s, synthetic forms of Ascorbic acid, High Fructose Corn Syrup, Vegetable Oils, Canola Oil, Fluoride, etc.

    Are you currently using any of the items from the previous question? If so, please list which ones.

    Some additional questions:

    1. What are your expectations from this consult/process?

    2. How open are you to change the way you think about the root cause of your health problems?

    3. How committed are you to improving your health?

    4. How quickly do you expect to regain your health?

    5. What has brought you to consult with me and use HTMA and mineral balancing?

    6. Have you heard of the root cause protocol before?

    7. Are you familiar with Morley Robbins and his work. If so, have you watched his theory of everything video?

    8. How do you feel about iron supplementation?

    Final thoughts?

    Is there any extra relevant information of your history that hasn’t yet been covered? Any major stresses in your life, events or situations which may help me support you better? Please list below.