• FMP IFM Questionnaires

    Patient Health Information
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    Pick a Date
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    Pick a Date

  • IFM Medical Symptoms Questionnaire (MSQ)

    SFM New Patient Health Information

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • (c) 2015 The Institute for Functional Medicine

  • Please rate each of the following symptoms based upon your typical health profile for the past 14 days.

    Point Scale

     0  Never or almost never have the symptom
     1  Occasionally have the symptom, effect is not severe
     2  Occasionally have the symptom, effect is severe
     3 Frequently have the symptom, effect is not severe
     4  Frequently have the symptom, effect is severe
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  • {totalMsq}

    Total MSQ Calcuation

  • IFM Candida Screening Questionnaire

    SFM New Patient Health Information

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • (c) 2015 The Institute for Functional Medicine

  • Answering these questions will help you and your clinician decide if yeast may be contributing to your health problems.

    For each section, read the directions and score as indicated. The score for each section is calculated after each section. The total score is calculated at the end of the form.  

  •  
  • {sectionA176} our of a possible 19 points

    Section A Score

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  • {sectionB} out of a possible 225 points

    Section B Score

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  • {totalScore}

    Total Score

  • {sectionC190} out of a possible 96 points

    Section C Score

  • IFM Toxic Exposure Questionnaire

    SFM New Patient Health Information

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • (c) 2017 The Institute for Functional Medicine

  • Please check the best response for each of the following questions. Your provider will dicuss your answers with you.

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  •  {foodAnd379} out of 18 possible points 

    Food and Water Score

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  •  {homeAnd381} out of 30 possible points 

    Home and Work Environment Score

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  •  {travelAnd383} out of 15 possible points 

    Travel and Recreation Score

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  •  {totalToxic} out of 90 possible points 

    Total Toxic Exposure Score

  •  {medicalAnd385} out of 27 possible points 

    Medical and Personal Care Score

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • IFM Questionnaire Summary

  • IFM MSQ Total Score:{totalMsq}

    IFM Candida Questionnaire Summary

    Section A Score {sectionA176}
    Section B Score  {sectionB}
    Section C Score  {sectionC190}
    Total Candida Score  {totalScore}

     

    Men Women Interpretation
    40 or below  60 or below  Yeast is less apt to cause health problems 
    41-90 61-121 Yeast-connected health problems are possibly present 
    91-140 121-180 Yeast-connected health problems are probably present
    141+ 181+ Yeast-connected health problems are almost certainly present

     

    IFM Toxic Exposure Questionnaire Summary

    Food and Water Exposure   {foodAnd379} out of 18 possible points
    Home and Work Exposure   {homeAnd381} out of 30 possible points 
    Travel and Recreation Exposure   {travelAnd383} out of 15 possible points
    Medical and Personal Care   {medicalAnd385} out of 27 possible points 
    Total Toxic Exposure Score  {totalToxic} out of 90 possible points

     

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