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Functional Medicine Intake Form

Please complete before your first session

Client Intake Form

Complete all 15 sections before your first session. Required fields are marked with an asterisk. Your answers are emailed to Lisa. They are not added to the mailing list.

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Section 1 of 15

Personal Information

Full Name *Date of BirthPhoneEmail *AddressCityProvince / State / CountryReferred byAppointment Date

Health Goals & Primary Concerns

What brings you here today? Top 1–3 health goals?When did these concerns begin?Overall Health Score Right Now1 (poor) to 10 (excellent)What would a 10 look like for you?

Medical History

Current or past diagnosed conditions: Type 2 Diabetes Insulin Resistance / Pre-Diabetes Metabolic Syndrome Hypoglycemia Hypothyroidism / Hashimoto's Hyperthyroidism / Graves PCOS Menopause / Perimenopause Cardiovascular Disease Hypertension Elevated Cholesterol / Triglycerides Fatty Liver (NAFLD) SIBO IBS / IBD GERD / Acid Reflux Dysbiosis / Leaky Gut Celiac Disease Food Allergies / Sensitivities Chronic Fatigue Fibromyalgia / Chronic Pain Anxiety / Depression Autoimmune Condition Cancer (current or past) Sleep Apnea

Other conditions:Past surgeries or significant procedures (include dates):

Medications & Supplements

Current prescription medications:Vitamins, minerals, herbs, or other supplements:Antibiotic use history:

Metabolism & Mitochondria

Current weight (optional)Weight 1 year ago (optional)HeightBlood type (if known)Weight history:Genomic or mitochondrial testing (if known)CoQ10, PQQ, or Ubiquinone use

Energy patterns throughout the day: Consistent energy all day Morning crash Post-meal fatigue / brain fog Afternoon slump Wired at night / can't wind down Generally low energy all day Noticeably more energy in my youth than now

Do you experience any of the following? Strong sugar / carb cravings Mood changes when hungry Energy crash after meals Difficulty losing weight despite effort Unexplained weight gain Frequent urination / thirst Brain fog / poor concentration Hair thinning or loss Cold hands / feet Irregular or painful periods PMS / PMDD Hot flashes / night sweats Low libido Erectile dysfunction Skin changes (acne, dryness, rashes) Joint pain or stiffness Frequent illness / slow recovery

For women, menstrual & reproductive history:Hormone therapy or hormonal herbs (current or past):

Microbiome

Bowel movement frequency: 1–2 times/day (ideal) 3+ times/day Every other day Less than every other day

Stool consistency: Hard / pellet-like Formed & easy to pass (ideal) Loose / mushy Watery / urgent

Digestive symptoms: Bloating Gas / flatulence Heartburn / reflux Nausea Abdominal pain or cramping Constipation Diarrhea Alternating constipation & diarrhea Undigested food in stool Greasy / floating stools Food intolerances Mucus in stool

Food allergies, intolerances, or foods you avoid:Significant gut infections or food poisoning history:

Nutrition & Lifestyle

Describe a typical day of eating:

Current dietary approach: No specific approach Low carb / ketogenic Intermittent fasting Gluten-free Dairy-free Plant-based / vegan Paleo / whole food AIP (Autoimmune Protocol)

Other dietary approach:

Percentage of meals home-cooked: Less than 25% 25–50% 50–75% 75–100%

Foods regularly consumed: Refined sugar / sweets Processed / packaged food Fast food Alcohol Soda / diet soda Coffee Gluten Dairy

Foods you crave:Have you tried fasting? What kind, and how did it go?

Sleep

Average hours of sleepUsual bedtime

Sleep concerns: Difficulty falling asleep Waking during the night Waking unrefreshed Snoring / sleep apnea Vivid dreams / nightmares Sleep generally good

Additional sleep notes:

Stress & Nervous System

Current stress level1 (none) to 10 (extreme)Primary source of stress:How do you currently manage stress?Significant trauma or adverse life events affecting your health today:Type of exerciseFrequency per weekHow connected do you feel to friends, family, or community?1 (isolated) to 10 (deeply connected)Notes on social connection:

Mind & Mindset

Current mood concerns: Anxiety Depression Mood swings / irritability Low motivation Motivated / good drive Low energy Brain fog Difficulty concentrating Memory concerns Adapts well to change Low adaptability to change Generally stable and well

Additional notes:Are you stuck in a particular behavior that may be keeping you from accomplishing your health goal?How stuck do you feel by this pattern?1 (not stuck) to 10 (very stuck)

Environmental Exposure

Known exposures: Mold / water-damaged building Heavy metals (mercury, well water) Chemical / pesticide exposure Second-hand smoke Mercury amalgam dental fillings Root canals Air quality concerns None known

Additional notes:

Family Health History

Conditions in immediate family: Type 2 Diabetes Cardiovascular disease / heart attack Stroke Cancer (specify below) Thyroid disease Autoimmune conditions Dementia / Alzheimer's Mental health conditions Obesity / metabolic disease Digestive conditions

Additional family health patterns:

Current Health Team & Recent Testing

Other practitioners you are currently seeing:Most recent lab work or testing:

Your Health Story

At what point in your life did you feel your best, and what was different then?Is there anything else, physical, emotional, or contextual, important for me to understand?What does success look like for you 90 days from now?

Readiness & Support

How ready are you to make lifestyle changes? Very ready, I'm committed Ready but need guidance Somewhat ready, have some barriers Still exploring

Support at home: Yes, family / partner on board Somewhat Navigating independently

Anything that might get in the way?Anything else you'd like Lisa to know?

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