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 addressing them is the best way to deal with health challenges. Your careful consideration of each of the following questions will allow for more effective use of your scheduled consultation time. These questions will help identify underlying root causes of your symptoms and will also assist in formulating a Personal Health 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 an 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.)