Adult Functional Medicine Questionnaire

The adult intake questionnaire below is a standard wellness client intake form used in Functional Medicine to get a more complete health history.

Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying root causes of illness and will also assist us to formulate a treatment plan.

 
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Name *
Name
Today's Date *
Today's Date
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Gender *
Did you feel safe growing up? *
Have you been involved in abusive relationships in your life? *
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *
Do you feel safe, respected and valued in your current relationship? *
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *
Would you feel safer discussing any of these issues privately? Would you prefer not to speak about these issues? *
Do you consume the following? Check all that apply. *
How many Bowel Movements (BM) do you have per day? *
Have you ever used recreational drugs? *
Are you exposed to secondhand smoke regularly? *
Congratulations, you are on the path to taking your first step towards health and wellness! *
I have read and understand everything on this page. I acknowledge Dawn Bergeron and her associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Dawn Bergeron, her lab partners, her independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.