Functional Medicine Form -

Please select the areas of health you would like to improve *

Lose Weight

More Energy

Sleep Better

Improve Digestion

Improve Blood Work

Prevent Problems

Anti-Aging Support

Improve General Health

If you could improve just ONE thing about your health, what is the priority? *

I have difficulty falling asleeр * *

I wake up throughout the night * *

I frequently feel "wired" in the evenings * *

I have energy highs and lows throughout the day * *

I feel tired all the time * *

I need caffeine to get going in the morning * *

I usually go to bed after 10 pm * *

I frequently get less than 8 hours of sleep per night * *

I get fatigued easily * *

Things I used to enjoy seem like a chore lately * *

My sex drive is lower than it used to be * *

I have been experiencing feelings of depression such as sadness or loss of motivation * *

If I skip meals I feel low energy or foggy and disoriented * *

My ability to handle stress has decreased * *

I find that I am easily irritated or upset * *

I tend to overwork with little time for play or rleaxation for extended periods of time * *

I frequently skip meals or eat sporadically * *

I am experiencing muscle aches and headaches * *

I have had one or more stressful major life events * *

1. What are your weigh loss goals? *

Lose 5 - 15 lbs
Lose 16 - 30 lbs
Lose 31 - 50 lbs
Lose 51 - 100 lbs
Lose 100+ lbs
I just want to be healthy

2. When do you want to reach your goal weight? *

2 weeks
4 weeks
12 weeks
6 months
1 year

3.What is your commitment level to losing weight? *

I'm extremely motivated
High
Average
Low
I need constant encouragement

1. Do you or someone else in your houehold cook or prepare meals most days of the week? * *

Yes

2. How often do you eat out? * *

I eat out for every meal including weekends
I eat out for every meal during the work week
I eat out on occasion
I rarely eat out

1A. Once you start eating, do you find it difficult to stop? * *

Yes

1B. Do you crave foods such as breads, pastas, baked goods, and chips? * *

Yes

1C. When you eat grains, do you feel tired, sluggish or bloated? * *

Yes

1D. Have you been overweight for one year or longer? * *

Yes

2A. Are you stressed? * *

Yes

2B. Even when you eat healthy and exercise, is it hard for you to lose weight? * *

Yes

2C. Are you concerned about having a sluggish thyroid? * *

Yes

2D. Do you have a problem falling and/or staying asleep at night? * *

Yes

2E. Have you been diagnosed with hyperthyroidism (Over-active thyroid)? * *

Yes

3A. Do you eat at least 25 grams of fiber daily? * *

Yes

3B. Do you skip meals or go more than 4 hours without eating (While awake)? * *

Yes

3C. Do you eat breakfast within 1 hour of waking? * *

Yes

4A. Do you consume quality protein within 45 minutes of exercising? * *

Yes

4B. At every meal including snacks, do you consume protein? * *

Yes

4C. When you lose weight do you feel like you also lose energy and strength? * *

Yes

5A. Do you feel tired, unalert, and lacking energy most days? * *

Yes

5B. Do you feel like you're stuck in a plateau? * *

Yes

5C. Do you feel like your metabolism needs a boost? * *

Yes

5D. Are you sensitive to caffeine or stimulants? * *

Yes

6A. Do you feel like you lose weight slowly? * *

Yes

6B. Do you want to promote reduction in Body Mass Index (BMI)? * *

Yes

7A. Do you have excess fat on your stomach, hips, butt, or thighs? * *

Yes

7B. Do you want help to increase your lean muscle mass? * *

Yes

7C. Are you allergic to peanuts? * *

Yes

8. Do you currently take a daily multivitamin supplement? * *

Yes

9. Do you eat 6-12 cups of fresh vegetables daily? * *

Yes

10. Are you allergic to soy? * *

Yes

11A. Do you want help with appetite control and metabolism? * *

Yes

11B. Would you like a healthier alternative to coffee or tea that can also help with weight loss? * *

Yes

11C. Would you like a beverage that is full of healthy polyphenols (antioxidants) and has ingredients to decrease weight and body fat? * *

Yes

Wellness Intake Form