Functional Medicine

$150 fee for 1 hour functional medicine consultation

Full Name(Required)

Email(Required)

Phone(Required)

Date of birth(Required)

Driver's license number(Required)

Upload Driver's license

Max. file size: 5 MB.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Medical History(Required)

Any history of surgeries or major procedures?(Required)

Yes

If Yes please write in Details(Required)

Any food allergies? Foods to avoid? (This includes any negative reactions to gluten, dairy, sugar or alcohol)(Required)

Yes

If Yes please write in Details(Required)

REVIEW OF SYMPTOMS

If you have any of the symptoms below, please check the appropriate boxes, otherwise leave them blank !

General

Change in Appetite

Change in weight

Fatigue

Difficulty Sleeping

Anxiety

Depression

Hormones

Poor Motivation

Low Sex Drive

Poor sexual function

Brain fog

Irritability

Mood Instability

Irregular, Heavy or No Menstrual Periods

Skin

Sores That Don't Heal

Dry Skin

Hair changes

Allergies

Seasonal Allergies

Hives

Food Allergies

Eyes/ Nose/ Ears/ Mouth/ Throat

Loss of Vision

Difficulty Swallowing

Lump in the Neck

Voice Changes

Lungs

Shortness of Breath

Persistent Cough

Wheezing

Heart

Chest Pain

Heart Racing

Swollen Ankles

Gastrointestinal

Heartburn

Frequent Nausea

Abdominal Pain

Frequent Diarrhea/ Constipation

Musculoskeletal

Muscle/Joint Soreness

Generalized Weakness

Difficulty Recovering

Frequency of Bowel Movements(Required)

Frequency of Constipation(Required)

Frequency of Diarrhea(Required)

Frequency of Heartburn Acid Reflux Hiccups(Required)

Frequency of Bloating or After Meals(Required)

Frequency of Burping or Gas After Meals(Required)

When was your last blood work? (If within 6 months, please include results. If no recent panels have been done, we will go over what to get done together)(Required)

Within 6 months

No recent

Within 6 months report

Max. file size: 10 MB.

On a scale of 1-10, please rate your current sleep quality

How many hours nightly on average? How many times do you wake up through the night? Do you wake up energized in the morning?

Please describe your lifestyle and level of stress day to day?

Do you own and use a smart watch that tracks total daily calories and activity? (Apple watch, fitbit, galaxy)

Rough idea of current diet/macros?

How many meals do you prefer to eat?

Current training schedule and rep schemes?

What time of day do you normally train?

Current cardio regiment (if any) ?

Current supplements used (otc and advanced)?

Are you currently prescribed or using any medications including forms of Birth Control?

Yes

If Yes please write in Details

Full History (if any) with advanced supplements? (dosages and timeline for use)

Please be as detailed as possible with the questions below and attach posing/full body pictures in suit or equivalent with responses. (men do posing trunks or boxers)

Max. file size: 10 MB.

Select Gender(Required)

After selecting gender, please proceed below health questionnaire.

Male’s Health Questionnaire

Decline in your general well-being(Required)

None

Mild

Moderate

Severe

Extremely Severe

Chronic joint pain or muscular aches(Required)

None

Mild

Moderate

Severe

Extremely Severe

Excessive sweating(Required)

None

Mild

Moderate

Severe

Extremely Severe

Sleep problems(Required)

None

Mild

Moderate

Severe

Extremely Severe

Increased need for sleep, often feeling tired(Required)

None

Mild

Moderate

Severe

Extremely Severe

Irritability(Required)

None

Mild

Moderate

Severe

Extremely Severe

Nervousness(Required)

None

Mild

Moderate

Severe

Extremely Severe

Anxiety(Required)

None

Mild

Moderate

Severe

Extremely Severe

Physical exhaustion(Required)

None

Mild

Moderate

Severe

Extremely Severe

Decrease in muscular strength(Required)

None

Mild

Moderate

Severe

Extremely Severe

Depressive mood(Required)

None

Mild

Moderate

Severe

Extremely Severe

Feeling that you have passed your peak(Required)

None

Mild

Moderate

Severe

Extremely Severe

Feeling burn out, having hit rock bottom(Required)

None

Mild

Moderate

Severe

Extremely Severe

Decrease in beard growth(Required)

None

Mild

Moderate

Severe

Extremely Severe

Decrease in ability/frequency to perform sexually(Required)

None

Mild

Moderate

Severe

Extremely Severe

Decrease in number of morning erections(Required)

None

Mild

Moderate

Severe

Extremely Severe

Decrease in sexual desire or libido(Required)

None

Mild

Moderate

Severe

Extremely Severe

Any other symptoms worth noting

Under each category below, please mark as many as you feel relate to you either currently or previously.

Category A: Please select each statement you feel you identify with(Required)

Category B: Please select each statement you feel you identify with(Required)

Female’s Health Questionnaire

Category A: Please select each statement you feel you identify with(Required)

I sometimes feel bloating or puffiness

I often feel irritable or experience mood swings.

I experience heavy, painful periods

I have gained weight or have difficulty losing weight, especially around my hips, butt, and thighs.

I have been told by my doctor that I have fibroids.

I sometimes cry over “nothing”.

I often get migraines or other headaches.

I sometimes experience brain fog.

Category B: Please select each statement you feel you identify with(Required)

Category C: Please select each statement you feel you identify with(Required)

I experience PMS seven to ten days before my period.

I get headaches or migraines around my period.

I feel anxious often.

I have painful, heavy, or difficult periods.

My breasts are painful or swollen before my period.

I feel agitated, irritable, or weepy before my period.

I have had a miscarriage in the first trimester.

I experience restless legs, especially at night.

I have had difficulty getting pregnant (after trying for six or more months)

Category D: Please select each statement you feel you identify with(Required)

I have abnormal hair growth on my face, chest, and/or abdomen.

I have acne.

I have oily skin and/or hair.

I have areas of darker skin (e.g., armpits, upper inner thighs near groin)

I’ve noticed thinning hair on my head.

I have skin tags.

I struggle with depression and/or anxiety.

I have been medically diagnosed by my PCP or OB/GYN with PCOS.

I have had difficulty getting pregnant (after trying for six or more months).

Category E: Please select each statement you feel you identify with(Required)

Category F: Please select each statement you feel you identify with(Required)

Category G: Please select each statement you feel you identify with(Required)

Category H: Please select each statement you feel you identify with(Required)

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$150 fee for 1 hour functional medicine consultation

REVIEW OF SYMPTOMS

Male’s Health Questionnaire

Female’s Health Questionnaire

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