Functional Intake Form

Please complete this form as thoroughly as possible. All information is kept confidential.

Patient Information

Full Name *

Email *

Phone *

Date Of Birth *

Street Address *

City *

State *

Country *

Postal Code *

Gender *

Male

Female

Other

Emergency Contact / Phone *

Occupation

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Genitourinary Symptoms

Trouble urinating

Kidney infection

Prostate trouble

Genitourinary Symptoms (Female Only)

Hot flashes

Irregular/absent cycle

Cramping/backache

Have you ever been diagnosed with cancer? *

Yes

No

Activity Level *

Very active – exercise regularly

Somewhat active – exercise periodically

Not very active – do not exercise

Past Medical History

Illnesses

Surgeries

Hospitalizations

Antibiotic use

Blood transfusions

Vaccinations

Physical trauma

Emotional trauma

Last physical exam

Environmental Exposures

Dental amalgams / root canals

Pesticides / fungicides

Mold exposure (when/where/current)

Tick bites or vector exposure

Other known infections/exposures (EBV, CMV, Lyme, etc.)

Medications & Supplements

Prescription medications (dose/frequency)

Over-the-counter medications

Supplements/herbal remedies

Family / Social History

Marital status *

Married

Divorced

Single

Occupation

Work hours

Smoking (type/amount)

Recreational drug use

Sexual history concerns

Dental History

Amalgams (fillings)

Amalgams removed (when/by whom)

Root canals

Cavitations

Frequent cavities

Reproductive History (If Applicable)

Pregnancies

Contraceptive use / HRT

Last menstrual period (LMP)

Typical cycle length

Menstrual flow

Light

Moderate

Heavy

Menstrual pain

None

Mild

Moderate

Severe

Last PAP / abnormal history

Breast exams/investigations

Diet & Nutrition

24-hour diet recall

Daily water intake (filtered?)

Coffee / Tea / Alcohol

Processed food frequency

Current diet approach

Food allergies/intolerances

First meal time

Last meal time

Acknowledgement & Signature

I certify that the information provided is accurate to the best of my knowledge.

Signature

Clear

Date

Our Clinic Location:

14255 SW 42nd St. Suite 103 Miami, FL 33175

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