Adult Functional Medicine Questionnaire

Please apply to work directly with me.

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

Once Jen has read your submission she will reach out over email about the status of your application.

 

Assuming you and Jen are a great fit for one another, the form content that you complete below will be discussed in your initial, 90 minute Health History session. The Health History and personal information shared on the health intake form will always remain 100% confidential.

Accurately assessing all the factors and comprehensively managing them is the best way to deal with health challenges. Your careful consideration of each of the following questions will enhance my efficiency and will provide for more effective use of your scheduled health history session. These questions will help to identify underlying root causes of existing imbalances and will also assist me in creating your custom program.

*Whenever possible, it is highly recommended that this form be filled out on a computer. Please be sure to fill it out completely in one sitting.

Gender:
Did you feel safe growing up?
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
Do you feel safe, respected and valued in your current relationship?
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

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

I have read and understand everything on this page. I acknowledge Jen Hoy is a functional medicine health coach and does not diagnose, cure, or treat any illness or disease. Further, the undersigned releases Jen Hoy, her lab partners, her 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.

How can I help you? Thanks for getting in touch!

Thrive Health Consulting © 2018 by Jennifer Hoy

Holistic Health Coach | thrivehealthconsulting.com | jen@thrivehealthconsulting.com

 

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Kitchen & Lifestyle Photos taken at the Home of Dawn McKenna

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