• Applicant 1 Health History

    SFM Applicant Health Information
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Languages Spoken*
  • Race*
  • Ethnicity*
  • Family History (Please mark all that apply):*

  • Medication & Supplements

    Applicant 1 Health History
  • {applicantName} {dateOf} {date}
    Name  Date of Birth  Date Completed

     

  • Enter Current Medications (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking medications.
  • Current Supplements (or upload below). Please press "Save and Add Row" after each entry to save. Leave blank of not currently taking supplements.
  • HIPAA Authorization to Transmit PHI by Email*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Social History

    Applicant 1 Health History
  • {applicantName} {dateOf} {date}
    Name  Date of Birth  Date Completed

     

  • Have you ever regularly smoked or used tobacco products?*
  • Have you ever regularly consumed alcohol?*
  • Have you ever regularly recreational drugs?
  • Have you ever regularly exercised?

  • Procedure/Vaccine History

    Applicant 1 Health History
  • {applicantName} {dateOf} {date}
    Name  Date of Birth  Date Completed

     

    • Please enter dates as two digit month, four digit year, (e.g. "02/2019").
    • For vaccines, enter the four digit year for each vaccine, (e.g. "2010, 2020").
    • If none, type "None". If unknown, type "Unknown".

  • Health Experience and Expectations

    Applicant 1 Health History
  • {applicantName} {dateOf} {date}
    Name  Date of Birth  Date Completed

     

  • Completion of the following questions is required for SFM Functional Medicine Platform consideration. Please do your best to provide the requested information.

  • Readiness Survey

    Applicant 1 Health History
  • {applicantName} {dateOf} {date}
    Name  Date of Birth  Date Completed

     

  • Please rate on a scale of 5 (very willing) to 1 (not willing). In order to improve your health, how willing are you to:*
    Rows
  • Confidence Rating*
    Rows

  • Acknowledgment and Consent

    Applicant 1 Health History
  • Should be Empty: