Functional Medicine New Patient Survey

  • FUNCTIONAL MEDICINE NEW PATIENT SURVEY

  • Please answer the following questions before your new-patient appointment. This will help our provider target your symptoms and issues to better custom tailor their plan to you.

  • How were you born? *
  • How were you fed?*
  • How do you describe your Sleep habits?*
  • How do you describe your level of Stress?*
  • How is your Work Environment?*
  • Have you worked around chemical toxins?*
  • Have you worked at a place that had asbestos or mold?*
  • How would you describe your Diet?*
  • Please describe your Bowel Movements*
  • Please describe their frequency*
  • How often do you feel Fatigued? *
  • Do you ever experience Brain Fog?*
  • Has anywhere you’ve lived had Water Leaks?*
  • Has anywhere you’ve lived had Mold?*
  • Do you have Silver dental fillings?*
  • Have you ever had COVID?*
  • Were you hospitalized?*
  • Did you take any Medications? *
  • Have you traveled outside the United States?*
  • Did you eat local food and drink local water?*
  • Do you have any Pets? *
  • Do you have any environmental or seasonal Allergies? *
  • Have you ever had a Tick bite? *
  • Have you had any Rashes? *
  • Do you have any Joint pain? *
  • Have you ever had Heartburn or Reflux? *
  • Do you take any Vitamins or Supplements? *
  • When was the last time you had bloodwork drawn? *
  • How would you describe your Menstrual Cycles? *
  • Have you ever had any Yeast infections?*
  • Should be Empty: