• FMP IFM Questionnaires

    Applicant Health Information
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  • IFM MSQ Total Score: {totalMsq}

  • Candida Total Score: {totalScore}

  • Men Women Interpretation
    40 or below  60 or below  Yeast is less apt to cause health problems 
    41-90 61-121 Yeast-connected health problems are possibly present 
    91-140 121-180 Yeast-connected health problems are probably present
    141+ 181+ Yeast-connected health problems are almost certainly present

     

     

     

  • Horowitz/MSIDS 38 Point Symptom Total: {finalScore}

    Scale used by Dr. Horowitz:

    0--20 points:         Tick borne illness not likely
    21--45 points:       Tick borne illness possilbe
    46 points or more: Tick borne illness highly likely
     

  • IFM Medical Symptoms Questionnaire (MSQ)

    (c) 2015 The Institute for Functional Medicine

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  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • Please rate each of the following symptoms based upon your typical health profile for the past 14 days.

    Point Scale

     0  Never or almost never have the symptom
     1  Occasionally have the symptom, effect is not severe
     2  Occasionally have the symptom, effect is severe
     3 Frequently have the symptom, effect is not severe
     4  Frequently have the symptom, effect is severe
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  • {totalMsq}

    Total MSQ Calcuation

  • IFM Candida Screening Questionnaire

    (c) 2015 The Institute for Functional Medicine

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  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

       

  • Answering these questions will help you and your clinician decide if yeast may be contributing to your health problems.

    For each section, read the directions and score as indicated. The score for each section is calculated after each section. The total score is calculated at the end of the form.  

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  • {sectionA176}

    Section A Score

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  • {sectionB}

    Section B Score

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  • {sectionC190}

    Section C Score

  • {totalScore}

    Total Score

  • Horowitz/MSIDS 38 Point Symptom Checklist

    Patient Health Information
  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

  • This is a questionnaire to determine the probability of your having Lyme disease and other tick borne disorders.

     

    Copyright ©Dr. Richard Horowitz, published in “How Can I Get Better: An Action Plan for Treating Resistant Lyme and Chronic Disease.” St. Martin’s Press, 2017. Empirical Validation of the Horowitz Multiple Systemic Infectious Disease Syndrome Questionnaire for Suspected Lyme Disease. Maryalice Citera*, Ph.D., Phyllis R. Freeman2, Ph.D., Richard I. Horowitz2, M.D., International Journal of General
    Medicine 2017:10 249–273. http://www.ncbi.nlm.nih.gov/pubmed/28919803

     

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  • {section1}

    Section 1 Score

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  • {section2209}

    Section 2 Score

  • {section3215}

    Section 3 Score

  • {finalScore}

    Final Score

  • Brain Region Localization Form

    (c)2019 Datis Kharrazian and the Kharrazian Institute
  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions.

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  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • Congratulations! You have now reached the end of SFM's Functional Medicine Program New Patient Application. You can review the information saved on the forms by using the "Back" buttom.

    When you are finished with these forms, please select the "Submit" buttom. A copy of the forms will be sent to the provided email. A staff member from Sparks Family Medicine will be in touch. Thank you! 

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