Adult Intake Form

We hope you will answer the questions on this medical history form as thoughtfully as possible. Many of the questions that follow may not seem directly related to your main complaint or reason for seeking care. However, the answers to these questions, as well as the information you provide in the office, will determine the individualized approach taken to begin your treatment. Please consider this an opportunity to write anything you think may be pertinent to your health that you may not have spoken with any other provider in the past. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

Today's Date*

Date

What is your name?*

First NameLast name

Date of Birth?*

Your date of birth

Gender Identity?

M/F/transgender M/ transgender F/decline to specify

Preferred Pronoun(s)

What is Your Home Address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your phone number?*

Email address?*

Email Address

Emergency Contact: name and phone

Who is Your Primary Care Provider? (Name and Office Phone # Please)

Would you like us to share records with your PCP?

Do you have health insurance that you would like to use for lab orders if possible?

Language

Race

Ethnicity

Please pick marital status from from drop down menu

Who do you live with?

Occupation?

Do you enjoy your occupation?

Sexual orientation

Heterosexual/ Homosexual/ Bisexual/ Asexual/ Other

How did you hear about us?

What is the reason for today's visit? Please include when any problems began?

What have you tried to improve any above problems?

Height

Weight

Usual Weight

Allergies to Medication? Please include what reaction you have.

Allergies to Foods? Include type of testing and symptoms when food ingested

Surgical History? Include dates if you recall

Hospitalizations? (For what? How long? Include dates if you recall.)

Current Medications and Supplements including condition you take them for:

Please list name, street address (including zip code), and phone number of your preferred PHARMACY for PRESCIPTIONS. *This will be saved to your chart*

What is your typical exercise regimen?

Are you a cigarette smoker?

YesNoQuit

Packs per day?

How many years?

Please describe your alcohol consumption. How much, what type, how often do you drink?

Your Medical History - Please check all that apply

Other? Need to clarify? Please type

General States of Health - Please check all that apply

Other? Need to clarify? Please type

I hereby certify that the above information is true and accurate to the best of my knowledge.

The Functional Medicine Center may contact me via SMS (Text Message) in response to my form. Privacy Policy is available to review at https://thefunctionalmedicinecenter.org/privacy-policy. By checking this box, you agree to receive SMS from The Functional Medicine Center

Please sign your name with attached stylus or mouse if completing at home. All data on this form is encrypted and is transmitted securely via SSL.*

Last Pap?

Length of Cycle?