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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.

First Name *

Last Name *

Address *

City *

State/Province *

Zip/Postal Code *

Email Address *

Phone Number *

Skype Name *

Birth Date *

Place of Birth *

Height (feet, inches) *

Weight (lbs) *

Occupation *

Referred By *

Describe Problem(s). What inspired you to enquire about this program today? *

What have you tried already (treatments/programs)? *

What have you tried already that has been successful? *

With whom do you live? *

(Include children, parents, relatives, and/or friends. Please include ages.) I.E. Marc, age 9, son

Do you have any pets or farm animals? If yes, where do they live? *

Have you lived or traveled outside of the United States or Canada? If so, when and where? *

Have you or your family recently experienced any major life changes? If yes, please comment:

Have you experienced any major losses in life? If so, please comment:

How much time have you lost from work or school in the past year?

Previous jobs:

Did you feel safe growing up? *

Have you been involved in abusive relationships in your life? *

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *

Do you feel safe, respected and valued in your current relationship? *

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *

Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues? *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

(as a child and adult)

How often have you taken oral steroids? *

(e.g., Cortisone, Prednisone, etc.)

What medications are you taking now? *

List all vitamins, minerals, and other nutritional supplements that you are taking now. *

Where you a full term baby? A preemie? Breast-fed or Bottle-fed? *

As a child did you eat a lot of sugar and/or candy? *

What is your typical daily diet? *

How much of the following do you consume each weeK? *

(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)

Are you on a special diet? *

Is there anything special about your diet that we should know?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *

Do you feel much worse when you eat certain foods? *

Example: fat, protein, carbs, etc.

Do you feel much better when you eat certain foods? *

Example: fat, protein, carbs, etc.

Does skipping a meal greatly affect your symptoms? *

Have you ever had a food that you craved or really "binged" on over a period of time? *

Do you have an aversion to certain foods? If yes, what foods? *

How many bowel movements (BM) do you have per day? *

Example: 0-1,1-2, 3 or more

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *

Do you have any intestinal gas? If so, when. *

How many times per week do you drink alcohol? *

Have you ever used recreational drugs?

Have you ever used tobacco? (If so, for how long?) *

Are you exposed to secondhand smoke regularly? *

Do you have mercury amalgam filings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones.

Do you feel worse at certain times of the year? *

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

Do doors affect you? If so, which ones?

How would you rate your current level of stress (0-10) zero being low, ten being high? *

Have you ever had psychotherapy or counseling?

List your hobbies and leisure activities: *

Do you exercise regularly? If so, how many times a week? *

What type of exercise is it?

Do you struggle with insomnia or interrupted sleep?

Do your parents or siblings have (or had) any health issues? If so, please explain:

Please add any other information you feel is important:

Congratulations, you are on the path to taking your first step towards health and wellness! *

I have read and understand everything on this page. I acknowledge Stephanie Jackson, The Freedom to Live, and associates are natural health practitioners and do not diagnose, cure, or treat any illnesses or disease. Further, the undersigned releases Stephanie Jackson, her lab partners, her independent representatives, associates, and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.