• Root Restore Health

  • Functional & Integrative Health Intake Questionnaire

  • Stanley Stark - Functional & Integrative Health Consultant
    Secure HIPAA Fax: 786-431-2595

     


    Virtual Consultations Available Nationwide

  • Welcome to Root Restore Health.

     

    Thank you for taking the time to complete this confidential health questionnaire. The information you provide will help us identify potential root causes of your symptoms and create a personalized plan to restore your health, vitality, and well-being.

     

     Your privacy is important to us. All information submitted through this form is kept confidential and handled in accordance with HIPAA privacy standards.

    This questionnaire typically takes 15-20 minutes to complete. The more detailed your answers, the better we can identify the root causes of your symptoms.

     



     

  • Personal Information

  • Date of Birth
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Shift Work?
  • Retired
  • Sex at Birth
  • How did you hear about Root Restore Health?

  • Instruction:

    Please rate each item on a scale from 0–10

    Based on your experience over the past 30 days.

    0 = No Stress / Excellent

    10 = Severe / Extreme Stress

  • Rows

  • Digestive Health

  • Rows
  • Digestive History: Have you had Gallbladder removed?
  • Appendix removed?
  • History of antibiotics?
  • If Yes:Approximately how many courses in your lifetime?
  • Which image below most closely resembles your usual bowel movement?
  • Has your stool pattern changed within the last 6 months?
  • Have you noticed any of the following? (Check all that apply.)
  • Rows
  • Food Cravings
  • Abdominal Pain Location
  • Family history of:

  • General Hormone Symptoms (Everyone)

    Rate each symptom from 0 (None) to 10 (Severe)
  • Rows
  • Menstrual Status:
  • Rows
  • Rows
  • Rows
  • Prostate Symptoms
  • Rows
  • Additional Questions for Everyone: Have you ever been diagnosed with:

  • Cardiometabolic Risk

  • Check all that applies

  • Environmental Toxin Exposure

  • Heavy Metals
  • Pesticides
  • Mold Exposure
  • Chemical Workplace Exposure

  • Sleep Assessment

  • Instruction: Please rate each item on a scale from 0–10 based on your experience over the past 30 days. 0 = No Stress / Excellent 10 = Severe / Extreme Stress

  • Rows

  • Lifestyle & Nutrition

  • Functional Health Consultation Consent

  • Root Restore Health provides educational and consultative wellness guidance designed to help identify potential root causes of chronic health conditions. Recommendations may include nutrition, lifestyle modification, supplement education, and functional laboratory discussions. These services are not intended to diagnose, treat, cure, or prevent disease and do not replace the care of a licensed physician. Clients understand that they remain responsible for all medical decisions and should consult their physician regarding medical conditions or medications. By signing below, you acknowledge that you understand the nature of this consultation and consent to participate.
  • Date:
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  • Should be Empty: