Custom Mineral Blend Intake Form
Thank you for answering the following questions. They will be very important as I formulate your custom blend to have the greatest efficacy and safety for your unique situation.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Please list all current medication you take including dose, and how often/time of day you take them.
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Please list all supplements you currently take, including the brand and dosage when available.
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Have you reacted poorly to any vitamins, minerals, or supplements in the past? If so, please describe what happened.
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Do you have any diagnosed medical conditions? Please list them.
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Have you ever been diagnosed with or treated for any of the following: Kidney disease, impaired kidney function, or kidney stones, Liver disease, Heart disease or heart rhythm problems, High or low blood pressure, Thyroid disease, Parathyroid disease, Diabetes, Anemia, Iron overload or hemochromatosis, High blood calcium or other abnormal calcium issues, Conditions affecting potassium or sodium balance
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Have you had your gallbladder removed?
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Are you currently pregnant, trying to conceive, or breastfeeding?
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Are you under the care of a physician for any condition that requires monitoring your mineral levels or supplement intake?
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Have you had recent bloodwork showing abnormal levels of any of the following: Iron or ferritin, Calcium, Potassium, Sodium, Magnesium, Vitamin D, Kidney function markers, Liver markers, Thyroid markers
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If available, please upload any recent labwork results.
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Has a healthcare professional instructed you to avoid, limit, or increase any specific vitamin or mineral?
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What are your three main health concerns or symptoms right now?
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What are your primary goals for using a custom mineral blend?
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Are you currently experiencing any of the following: Fatigue or low stamina, Brain fog or difficulty concentrating, Poor sleep, Feeling wired, anxious, or overstimulated, Muscle cramps, twitching, or restless legs, Heart palpitations, Constipation or loose stools, Headaches, Dizziness when standing, Hair shedding, Heavy menstrual bleeding
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Do you tend to be sensitive to supplements, medications, or dietary changes?
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Do you follow any particular diet or avoid any major food groups?
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Approximately how much water do you drink daily?
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Do you regularly consume electrolyte drinks, mineral drops, or heavily mineralized water?
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Do you use distilled or reverse-osmosis water as your primary drinking water?
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Do you experience frequent sweating through exercise, sauna use, physical work, or hot weather?
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Do you regularly consume caffeine or alcohol?
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Do you have any allergies or ingredient sensitivities?
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Is there anything else you would like considered when creating your formula?
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