Integrative Health Institute Prospective Patient Form
Please confirm your Full Name
*
First Name
Last Name
Please confirm your Email Address
*
Confirmation Email
example@example.com
Please confirm your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
If you were referred, please leaver their name.
Have you reviewed our website?
Please Select
Yes
Not yet
A little bit
Are you familiar with Functional Medicine?
Please begin your response with "yes" or "no".
Are you familiar with how a Membership-Based Model Functional Medicine practice can help you?
What health symptoms, if any, do you have that you want to resolve? If none, please let us know why you are looking for a Functional Medicine doctor.
Briefly tell us what you are doing right now to fix this problem or what you would like to start doing to achieve your health goals.
How long have you been experiencing this health concern? If you’re not dealing with any current issues, type: 'I’m healthy.'
Right now I …
Have the financial resources to invest in my health.
Have access to the financial resources to invest in my health.
Do not have the financial resources to invest in my health and I am going to stay exactly where I am.
When it comes to prioritizing your health, which best describes your current situation?
I’m ready to commit time and resources
I’m exploring my options
I’m unsure what’s right for me
Other
If taking an active role in your health were important to making progress, what steps would you be willing to take?
I’m willing to make changes to my diet and nutrition.
I’m open to incorporating regular movement or exercise.
I’m prepared to follow a supplement or treatment plan.
I’m committed to making time for appointments and follow-ups.
I'm curious and ready to learn more about the root causes of my health issues.
How interested are you in joining our practice?
High
Medium
Low
I am just looking for a doctor who takes my insurance.
New patient appointment availability is approximately 6 to 8 weeks out due to high demand. If an opening becomes available beyond that timeframe, would you still like us to reach out to you?
Please Select
Yes, I'm ok to wait. Please reach out.
No, I won't be interested after that.
It would depend on how long afterwards.
Maybe, I'm not sure.
Todays date:
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Day
Year
Date: This helps know when your form was submitted.
Finally, on the scale of ONE to I AM HEALTHY, how committed are you, to you?
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Submit
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