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 my 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 me in formulating a wellness plan. 

Name *
Name
Include children, parents, relatives, and/or friends. Please include ages. Example: Wendy, age 7, sister
Example: indoors/outdoors
yes or no
yes or no
yes or no
yes or no
yes or no
as a child and adult
(e.g., Cortisone, Prednisone, etc.)
List typical meals and snacks.
Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert
Example: fat, protein, carbs, etc.
Example: 0-1, 1-2, 3 or more
10 being the most stressed
*
I have read and understand everything on this page. I acknowledge Lydia Mendel is a natural health practitioner and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Lydia Mendel and her lab partners 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 natural health services.

Congratulations, you are on the path to taking your first step towards health and wellness!