FN New Patient Intake

Functional Nutrition New Patient Intake

Please fill this form out completely. This information is important to determine if the Functional Nutrition Program is a good option for you.
Name *

First Name Last Name
Please enter your date of birth *

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Email *
example@example.com
Who referred you to our office?
Please rate your overall health on a scale of 1-10
Why not a 10? What's missing or what could improve?
How motivated are you to make the changes needed to get your health to a 10?
What's your 'why'? Think about the reason you are seeking out a weight loss and nutrition program. What specifically do you want to change and why? (example: I want to lose weight so my knees don't hurt and I can play with my grandkids, etc)
Please rate your diet on a scale of 1-10
If you rated yourself less than an '8', please select the options below which are preventing you from a better diet.

Time to prepare healthy foods I don't have money for healthy foods I'm not sure what healthy foods are I am not motivated to be healthy
Please list the option that fits your eating habits most closely.

I eat fast food more than 3 times per week I eat fast food 1-3 times per week I eat fast food less than 3 times per month You couldn't pay me to eat fast food I eat out a lot but it's not fast food I think my food choices are pretty good - I eat organic here and there and try not to overeat I do my best to eat as clean as possible and rarely vary from this way of eating.
If you eat out frequently (fast food or other restaurants), please list your usual restaurants.
Please list any over the counter and prescription medications.
Please list any supplements you are currently taking.
Please indicate any history of high blood pressure in your family.

Myself My mother My father
Please indicate any history of diabetes in your family.

Myself My mother My father
Please indicate any history of cancer in your family.

Myself My mother My father
If you have been diagnosed with autoimmune disease(s) please list below
Have you undergone any bariatric surgical procedures (for weight loss)?

Yes Yes and I have gained the weight back No
Please enter your current weight and height.
Please enter your target/goal weight.
Please select the other weight loss programs you've tried in the past.

Weight Watchers Jenny Craig Nutrisystem
Please list anything you liked about these programs.
Please list anything you did not like about them.
Do you have a history of eating disorder(s)

Anorexia Bulemia Binge eating
Please list any known food allergies.
Please list anything else we haven't asked that may be relevant to your weight loss journey.
Functional Nutrition is offered by Gard Wellness Center and abides by Gard Wellness Center's HIPAA Policy and Procedures. Please review the policy below.
I have read and reviewed the HIPAA Policies and Procedures.

Clear
Thank you for completing this form entirely. Please click 'Submit' below. We look forward to working with you.
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Functional Nutrition New Patient Intake