Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Functional Medicine Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Health Timeline & Symptom History
Current Conditions
Environmental Exposure Assessment
Diet & Nutrition Log
Additional details
Current Supplements & Nutraceuticals
| Medication | Dose | How often |
|---|---|---|
Sleep Quality & Circadian Rhythm
Stress & Adrenal Health Screening
Gut Health & Digestive Symptoms
Known Allergies & Sensitivities
| Allergy | Reaction |
|---|---|
Toxin Exposure Inventory
Please bring to your visit: lab results
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Functional Medicine Intake Form template from formisoft.com. formisoft.com/intake-templates/functional-medicine-intake