Holistic Healing LLC™

Functional Health Intake Questionnaire

Name: _________________________________     Date: _________________

Date of Birth: __________________________     Age: __________________

Primary Health Concern: _________________________________________________________________

Scoring Instructions:
Rate each symptom based on the past 30 days.

    0 = Never     1 = Rarely     2 = Sometimes     3 = Always

Checkbox items (☐) = 1 point if checked.

Section 1 — Neurological / Cognitive

___   Brain fog / poor concentration

___   Poor memory

___   Headaches

___   Dizziness or faintness

___   Tingling in hands or feet

___   Poor coordination or balance

Section 1 Total: _______

Section 2 — Eyes, Ears, Nose & Throat

___   Stuffy nose / sinus congestion

___   Excessive mucus / post-nasal drip

___   Watery or itchy eyes

___   Blurred vision

___   Ringing in ears / ear pain

___   Frequent coughing / sore throat

___   Hoarseness / frequent throat clearing

___   Canker sores / cold sores

Section 2 Total: _______

Section 3 — Skin & Nails

___   Acne / hives / rashes

___   Dry skin / eczema / psoriasis

___   Flushing / rosacea

___   Excessive sweating

___   Skin or nail fungus

___   Brittle or discolored nails / white spots

Section 3 Total: _______

Section 4 — Cardiovascular & Respiratory

___   Irregular or rapid heartbeat

___   Chest pain or tightness

___   Shortness of breath / difficulty breathing

___   Asthma or bronchitis (current or history)

Section 4 Total: _______

Section 5 — Thyroid

___   Fatigue / frequently tired

___   Difficulty losing weight

___   Brain fog or poor short-term memory

___   Hair loss / thinning eyebrows or lashes

___   Dry skin / decreased sweating

___   Low or high heart rate

___   Low body temperature / cold hands and feet

___   Anxiety or depressed mood

___   Elevated cholesterol (diagnosed)

Section 5 Total: _______

Section 6 — Digestive / GI

___   Nausea or vomiting

___   Diarrhea or constipation (or alternating)

___   Heartburn / upper GI pain

___   Bloating / gas / belching

___   Lower abdominal pain

___   Pain immediately after eating certain foods

___   Abnormal food reactions (flushing, congestion, itching)

☐   History of H. pylori infection

☐   History of stomach ulcers

☐   Multiple rounds of antibiotics in lifetime

☐   Recurrent vaginal yeast infections

Section 6 Total: _______

Section 7 — Joints, Muscles & Bones

___   Joint pain or stiffness

___   Muscle pain or aches

___   Weakness or loss of strength

___   Restless legs

___   Bone pain

Section 7 Total: _______

Section 8 — Hormonal

___   Irregular periods / severe cramps / heavy bleeding

___   PMS / PMDD / mood swings before period

___   Premenstrual fluid retention or weight gain

___   Decreased sex drive

___   Hot flashes / night sweats

___   Vaginal dryness / pain with intercourse

___   Erectile dysfunction / poor erection quality

___   Migraines

___   Anxiety or panic attacks

☐   PCOS

☐   Endometriosis

☐   Uterine fibroids

☐   Infertility

☐   Fibrocystic breasts

Section 8 Total: _______

Section 9 — Adrenal / Stress Response

Check all that apply — 1 point per box

☐   Chronic emotional stress

☐   Fatigue / difficulty getting out of bed

☐   Faintness when standing quickly

☐   Low blood pressure

☐   Anxiety attacks / unexplained fears

☐   Shakiness or nausea when nervous

☐   Recurrent infections / slow recovery

☐   Chronic pain

☐   Sleep difficulties

☐   Allergies or asthma

Section 9 Total: _______

Section 10 — Weight & Mood

___   Unexplained weight gain (>5–10 lbs)

___   Unexplained weight loss (>5–10 lbs)

___   Fluid retention

___   Anxiety / worry / nervousness

___   Depression

___   Anger / irritability / mood swings

Section 10 Total: _______

Section 11 — Health History

Check all that apply — 1 point per box

☐   Autoimmune disease

☐   Thyroid disease or imbalance

☐   Cancer (current or history)

☐   Iron deficiency

☐   Carb or sugar cravings / never fully satisfied after eating

☐   Frequent illness / low white blood cell count

☐   Food poisoning or traveler's diarrhea

☐   Travel outside the USA

☐   Pancreatitis

☐   Itching (vaginal, rectal, or ears)

Section 11 Total: _______

Section 12 — Additional Notes

Is there anything else you'd like your practitioner to know?

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Commitment & Readiness

1 point per Yes

☐   I am committed to giving my best effort toward returning to health.

☐   I am willing to change my diet.

☐   I am willing to begin or modify an exercise regimen.

☐   I understand that healing takes time.

Section Total: _______

Section Totals Summary

Holistic Healing LLC™ is not a medical practice and does not provide medical advice, diagnosis, or treatment. This form is for educational and informational purposes only and does not replace the advice of a licensed healthcare professional. Always consult your physician before starting any new health regimen, supplement, or medication.