Women’s Health – Functional Medicine Questionnaire Basic InformationFull Name(Required)Email(Required) Phone(Required)DOB(Required) MM slash DD slash YYYY Height(Required)Weight(Required)Allergies(Required)Occupation(Required)Marital/Relationship Status(Required)Children (ages)Chief ConcernsPrimary health concerns or symptoms:(Required)When did they start?(Required)What do you hope to achieve from this consultation?(Required)Current Health & Medical HistoryCurrent diagnoses:(Required)Past illnesses, injuries, surgeries (with year):(Required)Hospitalizations:(Required)Current medications (name, dose, frequency):(Required)Current supplements/herbs (name, dose, frequency):(Required)Lifestyle & HabitsWake time:(Required) Hours : Minutes AM PM AM/PM Bedtime:(Required) Hours : Minutes AM PM AM/PM Hours slept:(Required)Well-rested?(Required) Yes No Screen use before bed:(Required) Yes No Exercise type/frequency/duration:(Required)Limitations/Injuries:(Required)Stress sources:(Required)Coping strategies:(Required)Stress rating (1–10):(Required)Tobacco use:(Required)Alcohol use:(Required)Recreational drugs:(Required)Caffeine use:(Required)Nutrition & DigestionTypical meals:(Required)Special diet:(Required)Food cravings:(Required)Aversions:(Required)Food intolerances/sensitivities:(Required)Appetite:(Required) Good Poor Variable Bloating:(Required) Yes No When do you have bloating(Required)Undigested food in stool:(Required) Yes No Bowel movements/day:(Required)Stool type:(Required)Heartburn/Reflux:(Required) Yes No Gas(Required) Yes No History gut infections/antibiotics:(Required)Functional Medicine Systems ReviewEnergy & Metabolism:(Required) Fatigue Midday slump Difficulty losing weight Weight gain Cold hands/feet None of the above Hormonal Health:(Required) PMS Irregular cycles Heavy bleeding Painful periods Hot flashes Night sweats Low libido Breast tenderness Hair thinning Acne Hair changes None of the above Age first period:(Required)Bleeding days:(Required)Cycle length:(Required)Clots?(Required) Yes No Last menstrual period(Required) MM slash DD slash YYYY Currently menstruating?(Required) Yes No Perimenopausal/Menopausal?(Required) Yes No Pregnancies:(Required)Live births:(Required)Miscarriages:(Required)Complications:(Required)Breastfeeding:(Required)Contraception/Hormone Use: Method:(Required)Birth control history? Years?HRT?(Required) Yes No HRT type/duration:(Required)Cardiovascular(Required) High BP High cholesterol Chest discomfort Palpitations SOB with exertion None of the above Musculoskeletal(Required) Joint pain Muscle soreness Back/neck pain Loss of flexibility None of the above Immune(Required) Frequent colds Seasonal allergies Autoimmune Chronic infections None of the above Cognitive/Mood:(Required) Brain fog Poor memory Low motivation Depression/anxiety Sleep disturbances None of the above Skin/Hair:(Required) Acne/rashes Hair thinning Brittle nails Dry skin Pigmentation changes None of the above Breast & Gynecological HealthFamily history breast/ovarian/uterine cancer:(Required) Yes No Last Pap smear:(Required)Result:(Required)Last mammogram:(Required)Result:(Required)Breast lumps/pain:(Required) Yes No Vaginal dryness:(Required) Yes No Recurrent infections:(Required) Yes No STD history(Required) Yes No Family HistoryHeart disease:Diabetes:Cancer (type):Stroke:Autoimmune disease:Alzheimer’s/dementia:Osteoporosis:Other:Lab HistoryRecent labs (bring/email 48–72 hrs prior):Past abnormal labs:Readiness & GoalsMotivation to make lifestyle changes (1–10):(Required)Please enter a number less than or equal to 10.Biggest obstacles:(Required)Support system:(Required)Additional NotesAnything else you’d like us to know:ConsultationsRequired Forms Preliminary forms must be submitted at least 10 days prior to your scheduled appointment. Forms may be picked up in-store or submitted on our website. If a question does not apply to you, please leave it blank. Scheduling & Payment We will contact you to schedule your consultation once all required paperwork has been received. A $50 deposit is required to reserve your appointment. This will be applied to the total consultation fee (varies by consultation type). Cancellations must be made at least 48 hours in advance. Late cancellations or missed appointments will result in a $50 cancellation fee, in addition to forfeiting the deposit. Consultation Details The initial consultation lasts 60–90 minutes. Bring the following to your appointment: All current medications All current supplements Recent lab test results Insurance & Payment Options We do not accept third-party insurance for consultations. Upon request, we can provide a claim form for you to submit to your insurance company for possible reimbursement after your appointment. You will receive a final report with personalized instructions at the conclusion of your appointment or via email the following day. Privacy & Confidentiality All information discussed during your consultation is strictly confidential. Records are maintained in compliance with HIPAA standards and current privacy laws. Motivation, willingness to change & support are crucial to the success of your health journey. CAPTCHA
