Functional Medicine Intake Form

The Functional Medicine Intake Form is designed for functional medicine practitioners, integrative health clinics, naturopathic physicians, and holistic wellness centers that take a root-cause approach to patient care. Unlike a standard medical intake, this integrative health intake form captures a comprehensive health timeline that maps the onset of symptoms to life events, environmental changes, and dietary shifts. It documents the full picture of a patient's biological, psychological, and social health determinants so the practitioner can identify the underlying triggers and mediators driving chronic illness.

This functional medicine patient intake template goes beyond conventional history-taking with dedicated sections for environmental exposure assessment (mold, heavy metals, pesticides, volatile organic compounds), detailed diet and nutrition logging (macronutrient balance, food sensitivities, elimination diet history), current supplement and nutraceutical lists with dosages, sleep quality and circadian rhythm assessment, perceived stress and adrenal health screening, gut health symptoms (bloating, motility, stool quality via Bristol chart), and a toxin exposure inventory covering occupational, household, and personal-care-product chemicals. The conditions checklist screens for the complex, multi-system presentations that functional medicine patients typically present with.

Ideal for practitioners who need patients to complete a thorough intake before the initial consultation, this form can be sent digitally and completed at home, giving the clinician time to review the data and prepare a personalized treatment plan. The medications list captures both prescription and over-the-counter drugs alongside herbal remedies, while the allergies section covers food, environmental, and chemical sensitivities. A consent agreement covers the functional medicine model of care, out-of-network billing practices, and lab testing authorization, ensuring both practitioner and patient begin the therapeutic relationship with clear expectations.