Health Intake and History FormMineralBalance Health Intake & History FormMineralBalance Health Intake & History FormPlease complete this form as thoroughly as possible. Your answers provide important context for reviewing your MineralBalance HTMA results and setting up your program. Most clients complete the form in approximately 10–15 minutes.Basic InformationFirst NameLast NameEmail AddressPhone NumberAgeBiological Sex- Select -MaleFemaleOccupationHeight (feet, inches)Weight (lbs)CityState/ProvinceHair Sample Type- Select -HeadPubicUnderarmChestHealth Concerns & Medical HistoryTop 3 Health ConcernsWhich concern is your highest priority?When did your symptoms first begin? Less than 3 months 3–12 months 1–5 years More than 5 yearsHave your symptoms been: Improving Stable Getting worse FluctuatingCurrent MedicationsCurrent Vitamins, Minerals & SupplementsMedical DiagnosesSurgeries or hospitalizationsFamily Health HistoryLifestyle & NutritionDiet Type- Select -OmnivoreVegetarianVeganKeto/Low CarbPaleo/PrimalCarnivoreMediterraneanOtherHow many full meals do you typically eat each day 1 2 3 4+Do you snack between meals? Never Occasionally Daily Multiple times per dayDescribe a Typical Day of EatingFood CravingsDaily Water Intake- Select -Less than 1 L1-2 L2-3 L>3 LCaffeine IntakeAppetite Poor Normal LargeAlcohol Intake Never Monthly Weekly Several times/week DailyExercise RoutineSleep HoursSleep Quality- Select -Excellent / RestedGood / ModeratePoor / Waking up tiredInsomniaBowel movements Less than once daily Once daily Twice daily Three or more dailyCurrent Stress Level (1-10)5Average Daily Energy Level (1-10)5Symptom ChecklistsSelect all symptoms that apply to you currently.Energy Fatigue / Exhaustion Low stamina Afternoon energy crash Difficulty waking up Poor exercise tolerance Insomnia / Difficulty falling asleep Frequent waking during the night Non-restorative sleep Night sweatsMood & Cognitive Anxiety Panic attacks Depression / Low mood Irritability / Mood swings Brain fog Poor concentration Memory problems Feeling overwhelmedDigestive System Bloating Excessive gas Constipation Diarrhea Alternating constipation/diarrhea Acid reflux / GERD Nausea Abdominal pain Food sensitivities Poor appetite Excessive appetiteBlood Sugar & Metabolism Sugar cravings Salt cravings Shakiness between meals Irritability if meals are skipped Frequent hunger Excessive thirst Frequent urination Difficulty losing weight Unexplained weight gain Unexplained weight lossThyroid & Temperature Regulation Cold hands or feet Cold intolerance Heat intolerance Low body temperature Excessive sweatingCardiovascular Heart palpitations Rapid heartbeat High blood pressure Low blood pressure Dizziness upon standing Poor circulation Cold extremities Swelling of hands or feetMusculoskeletal Muscle cramps Muscle weakness Muscle tightness Joint pain Joint stiffness Back pain Neck pain Osteoporosis / Osteopenia Slow recovery after exerciseSkin, Hair & Nails Hair loss / Thinning Dry hair Brittle hair Premature graying Dry skin Oily skin Acne Eczema Psoriasis Slow wound healing Brittle nails White spots on nailsNervous System Headaches Migraines Tingling or numbness Tremors Poor coordination Restless legs Sensitivity to light Sensitivity to sound Ringing in the ears (tinnitus)Urinary Frequent urination Urgency Frequent urinary tract infections Kidney stones Difficulty urinating Water retentionWomen PMS Painful periods Heavy menstrual bleeding Irregular menstrual cycles Missed periods Endometriosis PCOS Infertility Hot flashes Low libido Vaginal drynessMen Low libido Erectile dysfunction Decreased morning erections Reduced muscle mass Infertility Enlarged prostate symptomsEnvironmental & Toxic ExposuresThese questions help identify environmental and lifestyle factors that may influence mineral balance or contribute to heavy metal exposure.Dental HistoryWhich of the following apply? Silver/amalgam (metal) fillings currently present Silver/amalgam (metal) fillings removed Root canal(s) Dental implants Crowns Frequent dental workSmoking / Vaping Status Never Former Smoker Active Smoker OccasionalKnown Mold Exposure Yes, currently Yes, in the past No / UnknownPrimary drinking water source Municipal tap Filtered tap Reverse osmosis Well water Spring water Bottled water OtherDescribe any known toxic metal or chemical exposureOccupational ExposureHave you worked around any of the following? Welding Painting Manufacturing Construction Mining Dentistry Agriculture Solvents Pesticides Heavy metals Industrial chemicalsAdditional DetailsUploads & Additional CommentsUpload any recent lab tests to help us interpret your HTMA.Upload Recent LabsUpload Lab Files Additional CommentsConsent & AuthorizationConsent, Disclaimer, and DisclosureI request that Brian Brezinski perform a nutritional evaluation and set up a diet, supplement, detoxification, and lifestyle program for the purpose of enhancing health and improving well-being. I understand that all testing, techniques and supplements are recommended/provided for the purpose of reducing stress and balancing body chemistry and that Brian Brezinski is providing these services as an unlicensed nutrition consultant. None of the services/products recommended or provided are intended as diagnosis, treatment or prescription for any mental or physical disease, and are not intended as substitute for regular medical care.I have read, understand, and agree to the Consent, Disclaimer, and Disclosure above.Digital SignatureDateSubmit
