First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Address *

Street Address

City

State

Country

Postal Code

What are your current health concerns? *

What do you hope to get out of this HTMA programme? *

List any current diagnosed conditions *

Current symptoms not yet diagnosed

List all current medications, including dose, purpose, and how long you've been taking them. Include any hormonal contraception (oral, implant, IUD, patch, etc.) and HRT. *

List all current supplements, including dose, purpose, and how long you've been taking them. *

Past major health issues, surgeries, or hospitalisations *

Family history relevant to your current concerns

Describe your present and past occupations *

Activities and hobbies outside of work *

Typical hours of sleep per night and sleep quality *

Subjective stress level (1–10) *

Tobacco / vaping status *

Alcohol — typical quantity and frequency *

Diet log: list everything you have eaten and drunk in the last 24 hours *

Water source *

Dietary restrictions or patterns

Pregnancy or breastfeeding status

Recent significant illness or major life stressor in the last 6 months

Other healthcare practitioners currently involved in your care

Is there any additional information you'd like to share?

I understand HTMA is not a diagnostic test.
I understand Gary Moller is a Natural Health Practitioner under NZ regulations and not a registered medical practitioner.
I agree to continue working with my GP for any medical concerns and not change prescribed medication based on HTMA results without consulting my prescribing doctor.
I consent to PHT storing my responses and using them to interpret my HTMA report.
Your information is confidential. Precision Health Testing will not share or divulge your responses to any third party without your express written consent. Your data is used solely to interpret your HTMA results and inform your personal protocol.