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Functional Medicine Intake Form

Asks about health timeline & symptom history, current conditions, and environmental exposure assessment. Built for functional medicine practices collecting comprehensive root-cause intake data.

Questions
16
Pages
2
Time
about 4 min

Includes

  • Consent agreement
  • File upload
  • Medication list
  • Allergy list
  • Conditions checklist
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Your practice

Functional Medicine Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Functional medicine practices collecting comprehensive root-cause intake data
  • Integrative and naturopathic clinics assessing diet, toxins, and lifestyle factors
  • Holistic wellness centers onboarding patients with complex chronic conditions
  • Anti-aging and longevity clinics documenting baseline health and environmental exposures

What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Health Timeline & Symptom HistoryLong Text

Page 2 · Additional details

  1. Current Supplements & NutraceuticalsMedications
  2. Sleep Quality & Circadian RhythmLong Text
  3. Stress & Adrenal Health ScreeningLong Text
  4. Gut Health & Digestive SymptomsLong Text
  5. Known Allergies & SensitivitiesAllergies

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Functional Medicine Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Functional Medicine Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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