Integrative Health and Wellness Associates - Prospective Patient Information Form

Thank you for your interest in an integrative approach to optimizing your health! 

This form is designed to help us understand your health concerns and goals so that we can schedule a complimentary 10-minute Discovery Call to touch base and determine if our approach is the right fit for your needs.

Please complete all required fields, and we will be in touch soon!

Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
ZIP Code *
  How did you hear about Integrative Health and Wellness Associates/ Functional Ayurveda MD ™?   *
If you heard about us through a Doctor, Company, Friend, Family Member, or any particular website/Facebook group, please specify here: *
  What are your current symptoms and concerns?   *
  Have you been evaluated and/or treated by another medical provider for this concern?   *
 Have you explored Functional Medicine or Ayurveda in the past?   *
If yes, what have you tried?
Please share any methods, treatments, or approaches you have tried.  
Did it help?
Clear selection
  Do you have any major medical diagnoses and/or past medical history?  
  Please include any relevant conditions or previous treatments.  
 *
  What are your health goals?  
 This could include both short-term and long-term health objectives.  
 *
  On a scale of 1 (I'm not motivated) to 10 (I'll do anything): how ready are you to modify your lifestyle?   *
  On the same scale: how ready are you to significantly modify your diet?   *
  On the same scale: how ready are you to take nutritional supplements?   *
Consent & Acknowledgment 
 I understand that a Discovery Call does not establish a doctor-patient relationship *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Integrative Health and Wellness Associates, LLC.

Does this form look suspicious? Report

Google Forms