• Functional Medicine Male Intake Questionnaire

  • General Information

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  • Current Health Concerns

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  • Allergies

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  • Lifestyle Review

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    Sleep
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  • Exercise
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  • Nutrition
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    Diet
  • Please record what you eat in a typical day:

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

  • Smoking
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  • Alcohol
  • Other Substances
  • Stress
  • How much stress do each of the following cause on a daily basis

    (Rate on scale of 1-10, 10 being highest)

  • Relationships
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  • History

    Patient's Birth/Childhood History:
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  • Dental History
  • Environmental/Detoxification History
  • Men's History
  • Screens/Procedures: (If applicable, provide date)
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  • Family History
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    Medical History: Illnesses/Conditions (Check YES = 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 occur presently or have occurred in the last 6 months

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  • Current medications (include prescription and over-the-counter)

    Nutritional supplements (vitamins/minerals/herbs etc

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  • Medications/Supplements

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  • Readiness Assessment and Health Goals

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  • Health Goals
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  • Should be Empty: