Client Intake Form | Holistic Functional Medicine

01

Client Information

Basic details and the best way to reach you.

First name *

Last name *

Email *

Phone *

Date of birth

Pronouns

Address

02

Share what brought you here and what you want support with.

What are your top health concerns? *

What would you like to feel, improve, or understand better?

Areas you want support with Gut health Hormones Fatigue or low energy Stress or sleep Inflammation or pain Nutrition

03

Include diagnoses, surgeries, medications, supplements, and allergies.

Current or past medical conditions

Current medications

Current supplements

Allergies or sensitivities

Surgeries or hospitalizations

Primary care provider or specialist names

04

Daily patterns often explain what labs cannot show by themselves.

Sleep quality

Stress level

Describe your usual eating pattern

Movement or exercise routine

Digestion and bowel habits

05

Add anything else that would help your practitioner prepare.

Have you had recent labs or testing?

Anything else you want us to know?

Your completed form will be emailed securely through the form service to the business inbox.