Are you looking for answers as to why you feel the way you do?

intake-form

Intake Form

The adult intake questionnaire below is a standard wellness client intake form used in Functional Medicine to get a more complete health history.

Accurately assessing all the factors and comprehensively managing them is the best way to understand your health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying root causes of illness and will also assist me in creating a treatment plan.

(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister
Example: indoors/outdoors
(as a child and adult)
(e.g., Cortisone, Prednisone, etc.)
(List typical meals and snacks)
(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)
Example: fat, protein, carbs, etc.
Example: fat, protein, carbs, etc.
Example: 0-1, 1-2, 3 or more
  • “Let food be thy medicine and medicine be they food” ~ Hippocrates