Wellness Client – Lab Health Questionnaire

The health questionnaire below is a standard wellness client intake form used in Functional Medicine to get a more complete health history.

Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying root causes of illness and will also assist us to formulate a treatment plan.

Wellness Client - Lab Health Questionnaire

First Name *

Last Name *

Address *

City *

State *

Zip *

Email Address *

Time Zone *

Phone Number *

Birth Date *

Age *

Place of Birth *

Height (feet, inches) *

Weight (lbs) *

Gender *

Male

Female

Occupation *

Referred By (If working with an IHP coach, please list name) *

If your lab kit was purchased WITHOUT a health coaching call, please give your IHP coach's email address so they can receive a copy of your results *

Today's Date *

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Describe Problem(s): *

What treatments have you tried? *

Has anything been successful? *

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

How much time have you lost from work or school in the past year?

Please list any allergies or intolerances (food or environmental): *

List past Medical and Surgical History: *

List previous hospitalizations: *

How often have you taken antibiotics? *

(as a child and adult)

How often have you have taken oral steroids? *

(e.g., Cortisone, Prednisone, etc.)

What medications are you taking now? (including birth control/hormones) *

(e.g., Cortisone, Prednisone, etc.)

List all vitamins, minerals, and other nutritional supplements that you are taking now. *

What is your typical daily diet: *

(List typical meals and snacks)

How much of the following do you consume each week? *

(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)

Is there anything special about your diet that we should know?

Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplement(s)? *

How many bowel movements (BM) do you have per day? *

Example: 0-1, 1-2, 3 or more

Do you have any constipation (straining or less than 1 BM/day) or diarrhea (loose stool)? *

Do you have intestinal gas? If so, when. *

How many times per week do you drink alcohol? *

Do you have mercury amalgam fillings in your teeth? If so, how many? *

Do you have any artificial joints or implants? If so, which ones.

Have you, to your knowledge, been exposed to toxic metals in your job or at home? *

How would you rate your current level of stress? *

Women: If you have a cycle, how long is it and is it regular?

Women: Do you have any problematic symptoms related to your cycle?

Women: Any other comments related to your cycle? (flow, clots, mood changes, etc.)

Do you exercise regularly? If so, how many times a week?

What type of exercise is it?

Do you struggle with insomnia or interrupted sleep?

Do your parents or siblings have (or had) any health issues? If so, please explain:

Please add any other information you feel is important:

Congratulations, you are on the path to taking your first step towards health and wellness!

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I have read and understand everything on this page. I acknowledge Stephen Cabral and his associates are natural health practitioners and do not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Stephen Cabral, his lab partners, his independent representatives, associates and affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services.