Forms, Docs & Questionnaires 

Functional Medicine General Intake Questionnaire

PLEASE CHECK ANY OF THE FOLLOWING ISSUES AND/OR CONDITIONS THAT MAY APPLY TO YOU

FatigueSleepRashes or Skin ProblemsWord 3rd ShiftPoor memory, Cannot stay asleepChronic inflammation, infection, illness or pain, Achy JointsFainting Spells, No cold toleranceAbnormal blood sugar levels or hypoglycemia, Food CravingsDehydration, Crave SaltAsthma or chronic upper respiratory infectionsAllergies/Skin Blemishes, bruiseFear, anxiety or depression, chronic worry, low self esteemWeak/rigid nails, cracks in skinPoor digestion, Irritable bowel, cannot eat many foods, bloatingDry mouth, cracks in tongueFrequent skin redness, eczema like skin patches, frequent hivesHeadaches/MigrainesAttention/focus issues, learning difficultiesPoor Diet, Crave saltWeak Immune System/Frequently Sick, Autoimmune disordersObese and/or inability to lose weight (despite proper diet and exercise)Hormonal imbalances: PMS, Amenorrhea, Heavy Menses, Post-partum depression, Menopausal symptomsEndometriosis, Polycystic Ovaries, InfertilityFrequent Bladder Infections, DrynessHeart PalpitationsLow Libido