• SFM Applicant Health History

    Integrative Wellness Program
  • Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Languages Spoken*
  • Race*
  • Ethnicity*
  • Family History (Please mark all that apply):*

  • Medication & Supplements

    Integrative Wellness Program

  • {applicantName}

    		  

    {dateOf}

    		  

    {date}
    Name    Date of Birth    Date Completed

     

  • HIPAA Authorization to Transmit PHI by Email*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Social History

    Integrative Wellness Program

  • {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?

  • Dental History

    Integrative Wellness Program
  • Do you have or have you had root canals?*
  • Have you had wisdom teeth removed?*
  • Do you have or have you had silver (amalgam) fillings?*
  • Do you have dental implants?*
  • Do you have metal that has been used in dental work, such as gold?*

  • Health Experience and Expectations

    Integrative Wellness Program

  • Completion of the following questions are required for SFM Functional Medicine Program consideration. Please do your best to provide the requested information and use additional paper/documentation if necessary.

  • Health Experience and Expectations

    Integrative Wellness Program (cont.)

  • {applicantName} 

    		  

    {dateOf}

    		  

    {date}
    Name    Date of Birth    Date Completed

     

  • Health Experience and Expectations

    Integrative Wellness Program (cont.)

  • {applicantName} 

    		  

    {dateOf}

    		  

    {date}
    Name    Date of Birth    Date Completed

     

  • Readiness Survey

    Integrative Wellness Program

  • {applicantName} 

    		  

    {dateOf}

    		  

    {date}
    Name    Date of Birth    Date Completed

     

  • Rows
  • Rows

  • Acknowledgement and Consent

    Integrative Wellness Program

  • {applicantName}

    		  

    {dateOf}

    		  

    {date}
    Name    Date of Birth    Date Completed

     

  • Should be Empty: