Functional Medicine Consultation
Date of Birth
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Patient / Parent E-Mail
email@example.com (a copy of this form will be sent to this email)
Which program are you inquiring about?
Functional Medicine Evaluation
Thyroid Balance Program
Adrenal Balance Program
Diabetes/ Insulin Resistance Recovery
Integrative Pain Management Program
Please select any of the symptoms that apply to you:
Increase sensitivity to cold (compared to your norm, or compared to other people)
Muscle weakness, aches, tenderness or stiffness
Elevated blood cholesterol levels
Pain, stiffness or swelling of your joints
Heavier than normal or irregular menstrual cycles
Impaired memory or focus
Cravings for carbohydrates (simple carbs and sugars)
Sudden weight loss
Nervousness, anxiety, irritability
Tremor in hands or fingers
Increased sensitivity to heat
Fine, brittle hair
More frequent bowel movements
Rapid heartbeat (commonly over 100 beats per minute)
Red or swollen eyes
Poor stamina (extended periods of fatigue after exertion)
Difficulty getting up in the morning
Excessive coffee drinking
Dark circles under the eyes
Low blood pressure
Dizziness when sitting up or standing (POTS)
Inability to cope with stress (worse than before, or less than other people)
How long have you had the symptom(s) or condition(s) about which you are consulting us?
Less than 1 month
Less than 6 months
6 months to 2 years
More than 5 years
Please describe the nature of your concerns and what you hope to achieve for your well-being.
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, please give a general overview.
How did you hear about us?
Current or Previous Patient
We will contact you soon.
Our office will review the information on this form to determine your scheduling needs, then contact you with appointment options. Tip: Save our local (203-442-6740) and Toll-Free # (844-468-5963) to recognize when we call.
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