New Client Questionnaire - Susan Cachay HTMA Success

Welcome! Tell me about yourself.

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthdate

Age

Height

Weight

Gender

Male
Female

Occupation

Phone

Email*

How did you learn about me?

Consent*

I understand the terms & conditions.

I understand that: 1) Mineral-Nutritional Balancing is a means to reduce stress and balance body chemistry. 2) Susan Cachay is not a medical doctor. 3) Nothing here is intended to discourage me from seeking or following the advice of a medical doctor. 4) This is not meant to diagnose, treat or cure any diseases and isn’t a substitute for standard medical care.

What are your main health concerns or conditions?

Write the details of your health history starting when you can remember feeling well and on from there. Include any vaccinations, illnesses and trauma and their approximate dates.

What medications and/or supplements are you currently taking? (include Botox/Dyport if using now or used in the past)

List any ‘out of range’ (high or low) results from recent medical tests (e.g. blood tests).

List illnesses in your immediate family (e.g., heart disease, cancer, TB, diabetes, arthritis).

What kind of movement/exercise do you do and how often?

Approximately how many hours of sleep do you get each 24 hours and what is the quality?

List therapies, diets, supplements, medications etc. that you’ve found helpful.

List therapies, diets, supplements, medications etc. that haven’t worked well for you.

Diet

What are examples of typical breakfasts for you (including beverages)?

Mid-morning snacks?

What are examples of typical lunches for you (including beverages)?

Mid-afternoon snacks?

What are examples of typical dinners for you (including beverages)?

Evening snacks?

Health Issues & Life Experiences

Conditions / Symptoms

Men:

Impotence
Prostate Problems

Women:

Trauma:

Abuse - emotional
Abuse - physical
Abuse - sexual

Comments

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