Intake Form

Functional Medicine Health Questionnaire

The adult intake 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 your 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.

"Keep your vitality. A life without health is like a river without water."

– Maxime Lagace

What's Your Toxic Burden?

Don't wait until you're overflowing or flooding

We live in a world of 100,000+ invisible toxins.  Our bodies simply
can not keep up with the elimination.   We start to feel groggy, bloated, low energy, and slowly decline.

We don't have to accept these symptoms.  
Find your toxic load, detox, get to the root cause & create balance.