inf functional medicine (New Patient)
fill out this form a minimum of seven days prior to your initial inf functional medicine consultation.

please submit any lab work from the past five years, if available, via email.

Full Name *
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Today's Date *
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Street Address *
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City *
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State *
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Zip code *
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Email Address *
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Mobile Phone
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Home Phone
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Work Phone
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Date of Birth *
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Age *
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Height *
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Current Weight *
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Weight six months ago
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Weight one year ago
Your answer
Would you like your weight to be different? If so, what would you like it to be?
Your answer
Occupation *
Your answer
Number of hours you work per week *
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Referred by
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May I thank this person?
What are your five main concerns at this time in order of importance?
1.
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2.
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3.
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4.
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5.
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Any other major health concerns?
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When was the last time you felt really vibrant and well?
Your answer
Other current major life concerns?
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If you would wave a magic wand and change two things what would they be?
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Any serious illnesses, hospitalizations, injuries, and surgeries, either now or in your past?
Your answer
How is the health of your mother? (If deceased relay illness)
Your answer
How is the health of your father? (If deceased relay illness)
Your answer
What is your ancestry?
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What is your blood type?
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Do you sleep well?
How many hours?
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How often do you wake up in the middle of the night?
What do you think is the reason for your sleeping problems (if any)?
Your answer
Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
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What is your gender? *
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