Welcome to Our Wellness Clinic

Medical History Questionnaire

This is your medical history form, to be completed prior to your first visit with the Functional/Integrative physician/practitioners. All information will be kept confidential. This information will be used for your evaluation. The form is extensive, but please try to make it as accurate and complete as possible. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out. Your answers will help us design a comprehensive program that meets your individual needs.

If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.


(General Information)

Family Physician and/or Primary Health Care Provider:

What is (are) your purpose (s) for consulting a Functional/Integrative physician/clinic? To determine my current level of health and to receive recommendations for an individual health program.

Specific health concerns/symptoms (please explain)

List any additional health problems not listed:

Medication and Supplementation Information

List all current medications first then list all supplements you have been taking within the last year. Attach a separate page if additional room is needed.


Date: Started Stopped Dosage daily

Nutritional Supplements, Vitamins, Herbs, Homeopathic Remedies taken:

If not, what keeps you from exercising?
If yes, what type of exercise and how many times per week?

List Routine hobbies / sports / recreational activities

A 48-hour notice of cancellation is required. If a cancellation is less than 48 hours, you do not show or are over a half an hour Late for your appointment a rescheduling fee will be added to your next visit. We thank you for complying with this policy that has been proven to be very successful in helping us to care for patient needs.