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Intake Application Form: Adult Functional Medicine Questionnaire

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 deal with these 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 us to formulate a treatment plan.

(Include children, parents, relatives, and/or friends. Please include ages.) I.E. Marc, age 9, son
(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)
Example: fat, protein, carbs, etc.
Example: fat, protein, carbs, etc.