Functional Medicine Application
Yay! We're so excited to get to know you more. Please tell us your name.
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First Name
Last Name
What's your email? (So we can write back to you soon!)
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example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
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Friend/ word of mouth
Instagram
Website
Other
Do you live in the U.S. ?
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Yes
No
Do you have a recent history of cancer or are you currently being treated for cancer?
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Yes
No
Are you currently pregnant or breastfeeding?
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Yes
No
Have you worked with other Functional Medicine Practitioners in the past?
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Yes
No
Tell us what’s going on – please provide a description of your health struggles. What is your biggest challenge? What inspired you to fill out this application & seek a change? (Feel free to keep this brief - if we end up working together, you can drop the WHOLE story down on our first appointment!)
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What do you hope to achieve by working with us? (Dream big!)
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If you achieved all of these goals, how would you feel? If you felt like your best self, what would you do differently? How would it change your life?
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Have you done any functional testing/labs in the past? (Including, but not limited to, stool tests, SIBO breath test, H. Pylori breath test, hormone testing, adrenal testing, DUTCH test, organic acids test).
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What else have you done to try to solve your health issues? Why do you think you haven't been able to reach your health goals on your own?
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Since your health challenges began, how much have you invested in trying to solve these issues on your own? Consider the costs of programs, practitioners, appointments, copays, supplements, and other treatments you’ve tried.
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We see a limited number of individual clients so we can give our all to each case. Working within the private container of our 1:1 practice requires a significant investment. Knowing that this program will support you on your health journey, are you ready to make this investment into your health? Note: We DO accept HSAs & FSAs but do not take insurance.
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Yes! I am ready and able to make an investment to finally start feeling good again!
I am ready and able to make the investment, but I have some questions first!
I am not ready to make this investment at this time.
Which one best describes you?
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I am SO ready to start feeling like my best self and have the resources to do so. I would love to start a program ASAP
I am ready, but would love to speak with Dr. Em before I join
I am not prepared to make a decision at this time, and would like to learn about other options for working with Embody Wellness.
Any other relevant information you would like to add ?
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