Private Wellness Client Application

The health intake from 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 deal with 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 in formulating a treatment plan.

* = Required

Adult Health Intake Form

Please include relationship (child, parent, friend, sister/brother, etc.) and age. Example: "Wendy, age 7, sister"
(as a child and adult)
(e.g. Cortisone, Prednisone, etc.)
(list typical meals and snacks)
Tea, coffee, soda, other caffeine, dairy (milk/cheese/yogurt/butter, etc.), bread, sugar, candy, chocolate, dessert
(e.g. fat, protein, carbs, specific foods)
(e.g. fat, protein, carbs, specific foods)
(give a range, e.g. 0-1, 1-2, 2-3, 3 or more)
(flow, clots, mood changes, etc.)