FUNCTIONAL MEDICINE INITIAL INTAKE FORM

FUNCTIONAL MEDICINE INTAKE FORM
GENERAL INFORMATION
FULL NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AGE
GENDER
HIGHEST EDUCATION LEVEL
JOB TITLE
NATURE OF OCCUPATION/BUSINESS
CONTACT INFORMATION
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELL PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
WORK PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL
example@example.com
HOW DID YOU HEAR ABOUT US?
DOCTOR INFORMATION
PHYSICIAN'S NAME
PHYSICIAN'S PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
FUNCTIONAL MEDICINE QUESTIONNAIRE
ALLERGIES
ALLERGIES TO FOOD OR MEDICATIONS? REACTION?
COMPLAINTS AND CONCERNS
WHAT DO YOU HOPE TO ACHIEVE IN YOUR VISIT WITH US?
DESCRIBE ANY RECENT CHANGES IN YOUR HEALTH.
WHAT MAKES YOU FEEL WORSE?
WHAT MAKES YOU FEEL BETTER?
MEDICAL HISTORY - DISEASES / DIAGNOSES / CONDITIONS

Check the box next to the conditions you have
Gastrointestinal

Other
Cardiovascular

Other
Metabolic / Endocrine

Other
Cancer

Other
Genitourinary

Other
Musculoskeletal / Pain

Other
Inflammatory / Immune

Other
Respiratory Diseases

Other
Skin Diseases

Other
Neurologic / Mood

Other
Injuries - check box if yes:
Surgeries - Check box if yes and provide date of surgery in box below

Other and/or Dates of Surgery
Hospitalizations
Date Reason
Date Reason
Gynecological History (for women only)
Obstetric History (check box if yes and provide number below in "Other" box)

Other
Menstrual History
Age at first period
Menses Frequency
Length
Pain
Clotting
Has your period ever skipped?
Last menstrual period
Do you use contraception?
Contraception Type:
Hormonal Contraception:

How Long?
Women's Disorders / Hormonal Imbalances (for women only)
Last Pap test? Normal or Abnormal?
Are you in menopause?
Age at menopause?
Are you experiencing any of the following?
Use of hormone replacement therapy?
If yes, how long?
Men's History (for men only)
GI History
Foreign Travel
Where?
Wilderness Camping
Where?
Have you ever had severe:
Do you feel like you digest your food well?
Do you feel bloated after meals?
Dental History
Do you floss regularly?
Medications
Current Medications: Include medication name, dose, frequency, start date (mm/yy) and reason for use.
Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy): Include Supplement and Brand, Dose, Frequency, Start Date (mm/yy) and Reason for Use.
Have your medications or supplements ever caused you unusual side effects or problems?
If yes, describe:
Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin?
Have you had prolonged or regular use of Tylenol?
Have you had prolonged or regular use of Acid Blockers (Tagamet, Zantac, Prilosec, etc.)?
Frequent antibiotics? (>2 times / year)
Long-term antibiotics?
Use of steroids (prednisone, nasal allergy inhalers) in the past?
Use of oral contraceptives?
Nutrition History
Have you ever had a nutritional consultation?
Have you made any changes in your eating habits because of your health?
If yes, describe:
Do you currently follow a special diet or nutritional program?
Check all that apply:
Specific program for weight loss / maintenance type:
Other:
Height (feet / inches)
Current Weight
Usual Weight Range (+/- 5 lbs)
Desired Weight Range (+/- 5 lbs)
Highest Adult Weight
Lowest Adult Weight
Weight Fluctuations (>10 lbs)
Body Fat %
How often do you weigh yourself?
Do you avoid any particular foods?
If yes, types and reason:
Do you grocery shop?
If no, who does the shopping?
Do you read food labels?
Do you cook?
If no, who does the cooking?
How many meals do you eat out per week?
Check all the factors that apply to your current lifestyle and eating habits:
Smoking
Currently smoking?
How many years?
Packs per day?
Attempts to quit?
Previous smoking?
How many years?
Packs per day?
Second-hand smoke exposure?
Alcohol Intake
How many drinks currently per week? 1 drink = 5oz. Wine, 12 oz. Beer, 1.5 oz. Spirits
Previous alcohol intake?
Have you ever been told you should cut down your alcohol intake?
Do you ever feel guilty about your alcohol consumption?
Do you notice a tolerance to alcohol (can you "hold" more than others)?
Have you ever been unable to remember what you did during a drinking episode?
Do you get into arguments or physical fights when you have been drinking?
Have you ever been arrested or hospitalized because of drinking?
Have you ever thought about getting help to control or stop your drinking?
Other Substances
Caffeine intake?
Coffee cups / day
Tea cups / day
Caffeinated sodas or Diet sodas intake?
12 oz. can or bottle / day
Are you currently using recreational drugs (marijauna, ecstasy, etc.)?
If yes, what type?
Have you ever used IV recreational drugs?
Exercise
Current Exercise Program: (List the type of activity, number of sessions per week, and duration of sessions)
Rate your level of motivation for including exercise in your life?
List problems that limit activity:
Do you feel unusually fatigued after exercise?
If yes, please describe:
Psychosocial
Do you feel significantly less vital than you did a year ago?
Are you happy?
Do you feel like your life has meaning and purpose?
Do you believe stress is presently reducing the quality of your life?
Do you like the work you do?
Have you ever experienced major losses in your life?
Do you spend the majority of your time and money to fulfill responsibilities and obligations?
Would you describe your experience as a child in your family as happy and secure?
Stress / Coping
Have you ever sought counseling?
Are you currently in therapy?
Describe:
Do you feel an excessive amount of stress in your life?
Do you feel you can easily handle the stress in your life?
Daily Stressors

Rate on a scale of 1-10
Work`
Family
Social
Finances
Health
Other
Do you practice meditation techniques?
If yes, what technique and how often?
Have you ever been abused, a victim of a crime, or experienced significant trauma?
Sleep / Rest
Average number of hours you sleep per night:
Do you have trouble falling asleep?
Do you feel rested upon awakening?
Do you have problems with insomnia?
Do you snore?
Do you use sleeping aids?
If yes, explain:
Roles / Relationships
Marital Status
Number of children
Age of each child
Who else is living in the household?
Resources for emotional support (check all that apply)

Other
How well have things been going for you?
Overall in your life
At school
In your job
In your social life
With your friends
With sex
With your spouse / significant other
With your children
With your parents
With having a positive attitude
Environmental and Detoxification Assessment
Do you have known adverse food reactions and sensitivities?
If yes, describe symptoms:
Do you have any food allergies or sensitivities?
If yes, list all:
Do you have an adverse reaction to caffeine?
When you drink caffeine, do you feel:
Do you adversely react to any of the following?

Other
in your work or home environment, are you exposed to:
Do you have a known history of significant exposure to any harmful chemicals such as the following:

Other
Do you dry clean your clothes frequently?
Do you or have you lived or worked in a damp or moldy environment?
Do you have any pets or farm animals?
Readiness Assessment

Rate on a scale of 5 (very willing) to 1 (not willing). In order to improve your health, how willing are you to:
Modify your diet
Take several nutritional supplements each day
Modify your lifestyle (e.g., routines, sleep habits)
Practice a relaxation technique
Comments:
Rate on a scale of 5 (very confident) to 1 (not confident at all): How confident are you of your ability to organize and follow through on the above health related activities?
Comments:
Rate on a scale of 5 (very supportive) to 1 (very unsupportive): At this present time, how supportive do you think people in your household will be to your implementing the above changes?
Comments:
Should be Empty:

FUNCTIONAL MEDICINE INTAKE FORM

GENERAL INFORMATION

CONTACT INFORMATION

DOCTOR INFORMATION

FUNCTIONAL MEDICINE QUESTIONNAIRE

ALLERGIES

COMPLAINTS AND CONCERNS

MEDICAL HISTORY - DISEASES / DIAGNOSES / CONDITIONS

Hospitalizations

Gynecological History (for women only)

Menstrual History

GI History

Medications

Nutrition History

Smoking

Alcohol Intake

Other Substances

Exercise

Psychosocial

Stress / Coping

Daily Stressors

Sleep / Rest

Roles / Relationships

How well have things been going for you?

Environmental and Detoxification Assessment

Readiness Assessment