• Functional Gastro Female Intake Questionnaire

  • General Information

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  • Allergies

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  • Lifestyle Review

  • Sleep

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  • Exercise

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  • Nutrition

  • Please record what you eat in a typical day:

  • How many servings do you eat in a typical week of these foods:

  • If yes, check amounts:
  • If yes,
  • 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)

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  • 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

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  • Women's History

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    Pick a Date
  • Gynecological Screening/Procedures:

    (If applicable, provide date)
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  • Family History

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  • Medical History: Illnesses/Conditions

    Check YES = a condition you currently have, Check PAST = a condition you've had in the past.
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  • Symptom Review

    Please check if these symptoms occure presently or have occured in the last 6 months

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  • Medication/Supplements

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  • Readiness Assessment

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  • C 2015 The Institute for Functional Medicine

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  • Should be Empty: