Please record what you eat in a typical day:
How many servings do you eat in a typical week of these foods:
If you smoked previously:
How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)
Patient's Birth/Childhood History:
Age of introduction of:
Dental History:
Check if you have any of the following, and provide number if applicable:
Evnironmental/Detoxification History
C 2015 The Institute for Functional Medicine6
C 2015 The Institute for Functional Medicine
Symptom Review
Please check if these symptoms occure presently or have occured in the last 6 months