Integrative Health Institute Prospective Patient Form

Integrative Health Institute Prospective Patient Form
Please confirm your Full Name

First NameLast Name
Please confirm your Email Address

Confirmation Emailexample@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?
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 …
When it comes to prioritizing your health, which best describes your current situation?

Other
If taking an active role in your health were important to making progress, what steps would you be willing to take?
How interested are you in joining our practice?
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?
Todays date:

MonthDayYear
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?
Should be Empty: