Functional Medicine Intake Form

Functional Medicine Intake Form

Thank you for choosing Health Quest as part of your health care team! We look forward to assisting you in achieving your wellness goals, and to guiding you in maintaining your wellness throughout your life. To get started, please answer the following questions honestly and to the best of your knowledge. All information is kept confidential.

17. Please answer the following Yes or No:

27. Choose "Yes" if the feeling currently applies. Choose "In the Past" if you have felt that way in the past. Choose "Never" if you have never felt this way:

Injury Examples: cut on thumb, whiplash to neck, fall on left hip, broken right arm, etc.

Infection Examples: bronchitis, pneumonia, flu, sinus infection, etc.

Surgery Examples: c-section, appendectomy, etc.

Enter the verification code in the box below.