Functional Medicine Client Assessment Tool

As your coach, it’s important for me to understand how you view the world in general, yourself, your family, and your job or career. Each person comes from a unique place in their health and wellness, thinking, and in the way they interact with the world around them. In order to provide you with the best service possible, please take the time to complete this form with as much detail you feel comfortable. These answers will be treated with complete professional confidentiality.

PERSONAL INFORMATION

Name *

First

Last

Mobile Phone

Landline Phone

Email *

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Referred by:

PERSONAL STATISTICS

Age

Birthdate

Gender Identity

Height

Blood Type

Current Weight

Ideal Weight

Weight one year ago

Birth Weight (if known)

Birth Order (please list ages of biological siblings):

Your family and living situation

Example: Lives in house with wife and children. Other living situations would include living with in-laws, other relatives, children, and/or grandchildren, etc.

Number of Children and Pets

Your Occupation:

What do you like to do for Exercise?

May also include sports and recreation.

HISTORY

1. Have you lived or traveled outside of the United States? If so, when and where?

2. Have you or your family recently experienced any major life changes? If so, please comment:

3. Have you experienced any major losses in life? If so, please comment:

4. How much time have you had to take off from work or school in the last year?

0 to 2 days
3 to 14 days
more than 15 days

HEALTH CONCERNS

5. What are your main health concerns? Describe in detail, including the severity of the symptoms

6. When did you first experience these health concerns?

7. How have you dealt with these health concerns in the past?

Doctors
Self-care

8. Have you experienced any success with these remedies, approaches, and solutions? If yes, please explain.

9. What other health practitioners or specialists are you currently seeing? List specialists and reason.

10. List the date and description of any surgical procedures you have had (including breast reduction or augmentation).

11. How often did you take antibiotics in infancy/childhood? Please explain reason and frequency.

12. How often did you take antibiotics as a teen? Please explain reason and frequency

13. How often did you take antibiotics as an adult? Please explain reason and frequency.

14. List any pharmaceutical medicines you are currently taking.

15. List any vitamins, minerals, herbs and nutritional supplements you are currently taking and the reason.

16. Have any of your family members had similar health concerns or problems? Please list with description.

This would be mother, father, brother, sister, grandmother, grandfather, aunt, uncles, etc.

NUTRITIONAL STATUS

17. What foods do you avoid because of the way they make you feel or have a visible reaction from? If yes, list the food and the symptom:

Example: milk gives me mucus and stomach ache.

18. What symptoms do you have immediately after eating such as bloating, gas, sneezing, or hives? If so, please list symptom and frequency.

19. What delayed symptoms are you aware of after eating certain foods such as fatigue, muscle aches, sinus congestion, etc.? If so, please list food, symptoms, and frequency.

20. What foods do you crave? Please list what food and frequency of craving.

21. What diet or eating plan did you follow at the onset of your health concerns?

22. What known food allergies or sensitivities do you have? When were you tested or diagnosed?

23. Which of the following foods do you consume regularly?

24. Are you currently on a special diet?

24a. Are you currently on a special diet that is not listed above?

25. What percentage of your meals are home-cooked?

26. What else would you like to share about your current diet, history and/or relationship with food?

INTESTINAL STATUS

27. What is your frequency for Bowel Movements?

1 - 3 times per day
More than 3 times per day
Not regularly every day

28. What is your Bowel Movement Consistency?

29. What is your Bowel Movement Color

30. What experience do you have with intestinal gas? If so, please describe as excessive, occasional, odorous, etc.

31. Have you ever had food poisoning? If yes, describe in detail:

If yes, where were you when this happened? (travelling, at home, etc.) What did you use to treat your food poisoning? How long did it take to make a full recovery?

MEDICAL STATUS

32. Please check any of the following conditions that apply to your history and describe your symptoms, chosen treatment(s), and dates in the space provided below this checklist.

32A. What are your health conditions and briefly describe your symptoms, chosen treatments, and date of diagnosis (of the above checked conditions)

33. Please check the frequency of the following:

33a. Short term memory impairment

yes
no
sometimes

33B. Shortened focus of attention and ability to concentrate

yes
no
sometimes

33C. Coordination and balance problems

yes
no
sometimes

33D. Problems with lack of inhibition

yes
no
sometimes

33E. Poor organization abilities

yes
no
sometimes

HEALTH HAZARDS

34. What chemicals have you been exposed to? (Round-up, glyphosate, GMO) or toxic metals (lead, mercury, arsenic, aluminum) If so, please describe any symptoms from exposure.

35. What types of odors affect you? If so, please list item and symptoms.

Examples: perfume, scented candles, new car smell, soaps, etc.

36. When have you been exposed to second-hand smoke?

Please list frequency and any symptoms.

ORAL HEALTH HISTORY

37. What was the reason for your last visit with your Dentist?

38. In the past 12 months what has your dentist or hygienist talked to you about regarding your oral health, blood sugar, or other health concerns?

39. What is your current oral and dental regimen?

Please note whether this regimen is once or twice daily or occasionally. What kind of toothpaste you use?

40. Do you have any mercury amalgams (silver fillings)? If no, were they removed? If so, how long ago, and was it by a specialty dentist or regular dentist?

41. What concerns do you have about your oral or dental health?

42. What else about your current oral or dental health or health history would you like us to know?

LIFESTYLE HISTORY

43. What is your history with eating junk food, binge eating, or binge dieting? List any diet program(s) that you have been on for a significant amount of time.

44. What kinds of abuse or addiction have you had to alcohol, drugs, medications, tobacco, or caffeine? If yes, please describe.

45, What do you do to handle your stress?

SLEEP HISTORY

46. What about your sleep are you satisfied with?

47. What do you do to stay awake all day when you feel like dozing?

48. What do you do if you struggle to stay asleep between 2:00 a.m. and 4:00 a.m.?

49. Do you fall asleep in less than 30 minutes? If not, please explain.

50. What is your bedtime and how many hours do you sleep per night? If your sleep is broken up please list symptom and frequency.

FOR WOMEN ONLY

51. What was your age when you first began your menses (period)?

52. What are your periods like? Are they accompanied with painful cramps? PMS? How did you cope with your symptoms/challenges?

53. In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?

54. How often do you experience any yeast infections or urinary tract infections? What is your method of treatment?

55. Have you or do you take birth control pills? If so, please list the name brand and for length of time you've been on it.

56. What type of problems have you experienced with conception or pregnancy?

57. What kind of hormone replacement therapy or hormonal supportive herbs have you taken, tried, or currently taking? If so, please list.

58. What concerns with your sexual functioning would you like to share such as painful intercourse, dryness, low libido, etc.?

59. Have you addressed any of the above with your doctor or ob/gyne?

MENTAL HEALTH STATUS

60. How are your moods in general? Do you experience more anxiety, depression, or anger than you would like?

61. On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.

62. At what point in your life did you feel your best? Please explain.

OTHER STATUS

63. What family or friends will be supportive of you making health and lifestyle changes to improve your quality of life? Please describe your relationship and their ability to support you.

64. Who in your family or on your health care team will be the most supportive of you making a dietary change?

65. Please list and describe any other information you think would be useful in helping to address your health concerns:

66. What are your health goals and aspirations at this time?

67. Though it may seem odd, please list the reasons why you want to achieve these goals for yourself:

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