Functional Medicine Health Survey Name * First Name Last Name Date of Birth * What symptom or condition concerns you the most? Please write a diagnosis of the conditions you received (or major symptoms you experience) and when diagnosed (or started) Alcohol or wine None Once or Twice a Week Everyday Artificial Sweeteners None Once or Twice a Week Everyday Candy, desserts, refined sugar None Once or Twice a Week Everyday Soda drinks None Once or Twice a Week Everyday Cigarettes None Once or Twice a Week Everyday Chewing tobacco None Once or Twice a Week Everyday Electronic cigarette/pipes None Once or Twice a Week Everyday Recreational drugs None Once or Twice a Week Everyday Fast food None Once or Twice a Week Everyday Fried food None Once or Twice a Week Everyday Margarine None Once or Twice a Week Everyday Milk products None Once or Twice a Week Everyday Refined flour None Once or Twice a Week Everyday Tap water None Once or Twice a Week Everyday Distilled water None Once or Twice a Week Everyday Exercise None Once or Twice a Week Everyday Do you currently follow any of the following special diets or nutritional programs? (Select all that apply or skip if not) V Option 2 Do you have sensitivities, allergies, or reactions to certain foods? Y Option 2 Thank you!
