Functional Medicine New Patient Health Intake Form
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Functional Medicine New Patient Health Intake Form Template
A complete, printable new patient intake form designed specifically for functional medicine practices. Unlike a standard medical intake form, this template captures the full picture — diet, lifestyle, stress, environmental factors, and a system-by-system symptom review — giving you the clinical context needed for root-cause medicine before the first appointment.
Click the button to open your browser's print dialog. Select "Save as PDF" as the destination to download.
How to Use This Template
Download and Print
Click the "Download as PDF" button above and save the template to your computer. Print copies for your practice or send the PDF to new patients before their first appointment.
Send to New Patients
Include this intake form in your new patient welcome email or booking confirmation. Ask patients to complete it before their first appointment so you can review their history in advance.
Collect Before the Appointment
Having the completed intake form before the appointment means you walk in prepared. You can review the symptom checklist, medical history, and lifestyle factors ahead of time and use the appointment for deeper discussion.
Or Automate With Brevlix
Instead of managing paper forms or emailed PDFs, Brevlix turns this intake form into an interactive online assessment. Patients complete it on your website, responses are scored automatically, and you receive a structured clinical report before the appointment.
Intake Form Template
Section 1: Basic Information
Full name: _________________________________
Date of birth: _______________ Age: _______________
Email: _________________________________
Phone: _________________________________
How did you hear about this practice? _________________________________
Primary reason for seeking care: _________________________________
Section 2: Chief Complaint
What is your main health concern?
_________________________________________________
_________________________________________________
When did this start?
□ < 3 months □ 3-12 months □ 1-3 years □ > 3 years
How would you rate the severity?
□ Mild □ Moderate □ Severe
What have you tried so far? (check all that apply)
□ Conventional medicine □ Supplements / herbs
□ Diet changes □ Nothing yet
□ Other: _________________________________
Section 3: Symptom Checklist
Check all symptoms you experience regularly:
Digestive:
□ Bloating □ Acid reflux □ Constipation □ Diarrhea
□ Food sensitivities □ Nausea □ Abdominal pain
Energy & Mood:
□ Fatigue □ Brain fog □ Anxiety □ Depression
□ Sleep issues □ Irritability □ Difficulty concentrating
Musculoskeletal:
□ Joint pain □ Muscle aches □ Stiffness
□ Back pain □ Muscle weakness
Skin:
□ Acne □ Eczema □ Rashes □ Dry skin □ Hair loss
□ Brittle nails □ Skin discoloration
Hormonal (if applicable):
□ Irregular cycles □ PMS □ Hot flashes
□ Low libido □ Night sweats □ Heavy bleeding
Immune:
□ Frequent infections □ Autoimmune diagnosis
□ Seasonal allergies □ Slow wound healing
□ Chronic inflammation
Section 4: Lifestyle & Diet
Describe your typical daily diet:
_________________________________________________
_________________________________________________
Water intake: _______ glasses per day
Caffeine: _______ cups per day
Alcohol: _______ drinks per week
Exercise: _______ times per week
Type of exercise: _________________________________
Sleep: _______ hours per night
□ Fall asleep easily □ Wake during the night □ Wake up tired
Stress level (1-10, 10 = highest): _______
Primary stress sources (check all that apply):
□ Work □ Family □ Health □ Finances □ Other
Occupation: _________________________________
Typical work hours: _________________________________
Section 5: Medical History
Current medications (list all, including dosage):
_________________________________________________
_________________________________________________
Current supplements (list all, including dosage):
_________________________________________________
_________________________________________________
Past surgeries (type and year):
_________________________________________________
Diagnosed medical conditions:
_________________________________________________
_________________________________________________
Allergies (medication, food, environmental):
_________________________________________________
Family history (parents/siblings — check all that apply):
□ Autoimmune disease □ Thyroid disease □ Diabetes
□ Heart disease □ Cancer □ Mental health condition
□ None of the above
Section 6: Previous Testing & Providers
Have you had recent lab work?
□ Yes (approximate date: _______________) □ No
If yes, do you have copies of your results?
□ Yes □ No □ I can request them
Types of practitioners you have seen for your health concerns:
□ Primary care physician □ Gastroenterologist
□ Endocrinologist □ Naturopathic doctor
□ Functional medicine doctor □ Chiropractor
□ Acupuncturist □ Nutritionist / Dietitian
□ Other: _________________________________
Is there anything else you would like us to know before your appointment?
_________________________________________________
_________________________________________________
_________________________________________________
Brevlix Automates This Entire Intake Process
No more printing PDFs and manually collecting intake forms. Brevlix turns this intake form into an interactive, embeddable assessment that collects patient responses online and generates structured clinical reports automatically.
Start Free →Frequently Asked Questions
What is a functional medicine intake form?
A functional medicine intake form is a comprehensive health history questionnaire that goes beyond a standard medical intake. It captures diet, lifestyle, stress levels, environmental exposures, and a system-by-system symptom review — the data points functional medicine practitioners need for root-cause clinical analysis.
How is this different from a standard medical intake form?
Standard medical intake forms focus on current medications, allergies, and a brief medical history. This functional medicine intake form adds symptom checklists organized by body system, detailed diet and lifestyle assessment, stress evaluation, family history screening, and previous provider history — all data points that inform a root-cause clinical approach.
Can I customize this intake form for my practice?
Yes. You can download the PDF and add your practice logo, modify sections to match your clinical focus, or add specialty-specific questions. The template is designed as a comprehensive starting point that you can adapt to your needs.
Is this intake form HIPAA compliant?
The form itself is a template — HIPAA compliance depends on how you collect, store, and transmit completed forms. If you collect paper copies, store them in locked filing cabinets. If you collect them digitally, use a HIPAA-compliant platform. Brevlix provides a HIPAA-aware digital intake solution that automates collection and report generation.
How do I collect and store completed intake forms?
For paper-based workflows, have patients bring completed forms to their first appointment and store them in secured patient files. For digital workflows, Brevlix automates the entire process — patients complete the intake online, responses are scored and organized into a clinical report, and data is stored in your practitioner dashboard.