• Applicant 1 Health History

    SFM Applicant Health Information
  • Date*
     - -
  • Date of Birth*
     - -
  • 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

     

  • HIPAA Authorization to Transmit PHI by Email*
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  • 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

     

  • Rows
  • Rows

  • Acknowledgment and Consent

    Applicant 1 Health History
  • Should be Empty: