Promis- Global Health Questionnaire
Please complete this questionnaire for adults and children ages 13+
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rows
Excellent
Very good
Good
Fair
Poor
In general, how would you rate your health?
In general, how would you rate your quality of life?
In general, how would you rate your physical health?
In general, how would you rate your mental health, including mood and your ability to think?
In general, how would you rate your satisfaction with your social activities and relationships?
In general, how well do you carry out your usual social activities and roles? This includes activities at home, work, community, and responsibilities as a parent, friend, spouse, employee, etc.
Rows
Completely
Mostly
Moderately
A little
Not at all
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
In the last 7 days
Rows
Never
Rarely
Sometimes
Often
Always
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?
In the last 7 days
Rows
None
Mild
Moderate
Severe
Very severe
How would you rate your fatigue on average?
Rows
1
2
3
4
5
6
7
8
9
10
How would you rate your pain on average?
Total Score
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IntellxxDNA Agreement
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your DNA contains variants, or SNPs (single nucleotide polymorphisms), that may signal potential benefits as well as risks. Your DNA is not your destiny. In fact, understanding your genomic profile empowers you to make intelligent health and wellness choices now that may impact your future quality of life. Your doctor will review your genomic profile as one of several factors of consideration when making clinical decisions to help you achieve optimal health.
*
I understand
IntellxxDNA tests are not billable to insurance, are non-refundable, and cannot be transferred to another patient.
*
I understand
IntellxxDNA genomic reports are non-diagnostic.
*
I understand
IntellxxDNA is not a lab. Your specimen will be processed at third-party CLIA/CAP certified lab anonymously.
*
I understand
Patients cannot mail their specimen from the state of New York. Patients will be instructed to mail their specimen from outside of New York, for example, New Jersey, or Connecticut.
*
I understand
Due to the complexity of the tests performed in functional medicine, your doctor cannot answer questions about the results outside of a scheduled appointment.
*
I understand
By signing below, I acknowledge that my doctor or her staff has informed me of the out-of-pocket cost associated with the IntellxxDNA test. I confirm my understanding of this cost and consent to proceed with the test. I agree to the terms outlined above and authorize Healing Family Functional Medicine to use my credit card for payment on the IntellxxDNA provider portal. I understand that this payment is non-refundable and the transaction cannot be undone once processed.
*
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