HTMA SUBMITTAL FORM
FULL NAME:
*
First Name
Last Name
AGE:
*
SEX:
*
Please Select
Male
Female
N/A
CONTACT NUMBER:
*
EMAIL ADDRESS:
*
example@example.com
OCCUPATION:
*
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HEIGHT:
*
-
FT
IN
WEIGHT:
*
LBS.
TYPE OF SAMPLE:NATURAL HAIR COLOR:Type a question
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SCALP
PUBIC
AXILLARY
OTHER
NATURAL HAIR COLOR:
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BLOND
BROWN
BLACK
RED
PREGNANT?
*
Yes
No
Are you currently taking any medication?
*
Yes
No
Please list them.
PLEASE SPECIFY THE SHAMPOO AND OTHER HAIR PREPARATIONS
*
REQUIRED -WAS THIS SAMPLE COLLECTED IN THE STATE OF NEW YORK (PLEASE CHECK ONE).
*
Yes
No
DYES:
*
Yes
No
PLEASE CHECK FIVE MOST PREDOMINANT SYMPTOMS: (CLINICALDIAGNOSIS ONLY):
1 ALLERGIES (RESP)
2 ALLERGIES (FOOD)
3 ALLERGIES (ECOL)
4 ANEMIA
5 ASTHMAS
6 CANCER (type)
7 CANDIDIASIS
8 CATARACTS
9 CYSTIC FIBROSIS
10 DERMATITIS
11 DIABETES
12 ECZEMAS
13 EMPHYSEMAS
14 EPILEPSY
15 FATIGUE
16 GLAUCOMA
17 HEADACHES
18 HYPERKINESIS
19 HYPERCALCEMIA
20 HYPOGLYCEMIA
21 INFECTIONS (BACTERIAL)
22 INSOMNIA
23 IMMUNE DEFICIENCY (AIDS)
24 MONONUCLEOSIS
25 PSORIASIS
26 PERIODONTAL DISEASE
27 SCLERODERMA
28 VIRUSES
29 CHRONIC FATIGUE SYNDROME
30 HEMOCHROMATOSIS
MUSCULO-SKELETAL
31 ARTHRITIS- OSTEO
32 ARTHRITIS-RHEUMATOID
33 BURSITIS
34 CRAMPS (NIGHT)
35 CRAMPS (EXTETION)
36 DISC DEGENERATION
37 MUSCULAR DYSTROPHY
38 JOINT STIFFNESS
39 JOINT DISEASE
40 OSTEOPOROSIS
41 OSTEOMALACIA
42 OSTEOSARCOMA
43 PAGETS DISEASE
44 SCOLIOSIS
45 FIBROMYALGIA
46 LUPUS
CARDIOVASCULAR
47 ANGINA
48 ARTIOSCLEROSIS
49 ATHEROSCLEROSIS
50 HYPERCHOLESTEROLEMIA
51 HYPERLIPIDEMIA
52 HYPERTENSION
53 HYPERTENSION(SYSl)
54 HYPERTENSION (DIAS)
55 TACHYCARDIA
56 BRADYCARDIA
57 CORONARY OCCLUSION
GASTRO-INTESTINAL
58 CROHN'S DISEASE
59 COLITIS
60 CONSTIPATION
61 DIARRHEA
62 DIVERTICULOSIS
63 GASTRITIS
64 GALLSTONES
65 HEPATITIS
66 LIVER DYSFUNCTION
67 LIVER CANCER
68 ULCERS - GASTRIC
69 ULCERS - DUODENAL
70 IRRITABUE BOWEL SYNDROME
RENAL
71 BLADDER DISTURBANCES
72 CALCIUM OXALATE STONES
73 CALCIUM PHOSPHATESTONES
74 FREQUENT URINATION 504 GOUT
75 RENAL DISEASE
NEUROLOGICAL
76 ALZHEIMER’S
77 A.LS.
78 DYSLEXIA
79 MULTIPLE SCLEROSIS
80 MYESTHENIA GRAVIS
81 PARKINSONS DISEASE
82 DEMENTIA
83 STROKE
84 TOURETTE'S SYNDROME
EMOTIONAL
85 ANXIETY
86 ATTENTION DEFICIT
87 AUTISM
88 DEPRESSION
89 HOSTILITY
90 LEARNING DISABILITY 707 MEMORY LOSS
91 SCHIZOPHRENIA
92 MANIC DEPRESSION
ENDOCRINE
93 HYPERADRENIA
94 HYPERPARATHYROID
95 HYPERTHYROID
96 HYPOADRENIA
97 HYPOPARATHYROID
98 HYPOTHYROID
MALE
99 IMPOTENCE
100 PROSTATE CANCER
101 PROSTATE ENLARGEMENT
102 PROSTATITIS
FEMALE
103 AMMENORHEA
104 BREAST TUMORS (BENIGN)
105 BREAST TUMORS (MALIGNANl)
106 MENSTRUAL BREAST SORENESS
107 MENSTRUAL CRAMPS
108 MENSTRUAL IRREGULARITY
109 PROLONGED MENST. FLOW
110 DECREASED MENST. FLOW
111 PREMENSTRUAL SYNDROME
112 FIBROCYSTIC DISEASE
113 ENDOMETRIOSIS
114 OVARIAN CYSTS
Other
COMMENTS:
Are you experiencing any symptoms? If so, please describe them (e.g. fatigue, irritability, weight gain, etc.).
Yes
No
Not Sure
Please list them.
Do you have any food allergies?
Yes
No
Not Sure
Please list them.
How many cups of coffee do you drink per day?
*
How many cups of water do you drink per day?
*
On average, how many hours of sleep do you get per night?
*
How often do you have a bowel movement per week?
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