Dr. Jacqueline Morgan Van Montague

Functional Medicine Questionnaire

Please complete this intake form as thoroughly as possible before your consultation. Your answers help us create a personalized care plan.

Palm Beach Body Sculpting & Skin

Functional Medicine Intake Questionnaire

561-545-0359 | palmbeachsculptandskin.com

Patient Information

Full Name

Date of Birth

Address

City

State

Zip Code

Phone Number

Email Address

Occupation / Employer

Emergency Contact Name

Emergency Contact Phone

Primary Health Concerns

What are your top 3 health concerns?

What symptoms are bothering you most?

When did these symptoms begin?

Have your symptoms been getting worse, improving, or staying the same?

Getting worseImprovingStaying the same

What are your health goals for the next 6–12 months?

Current Symptoms — Check all that apply

Medical History

List all diagnosed medical conditions:

Surgeries (include dates):

Hospitalizations:

Medications & Supplements

Current Prescription Medications (Medication | Dose | Reason)

Supplements / Vitamins (Supplement | Dose)

Allergies

None

Please list allergies:

Family History

Nutrition

How many meals do you eat daily?

1234+

How many servings of vegetables daily?

0–12–34+

Water intake per day:

Less than 4 glasses4–8 glasses8+ glasses

Do you have food sensitivities?

YesNo

If yes, which foods?

Sleep

How many hours of sleep do you get nightly?

Under 55–67–88+

Do you wake feeling refreshed?

AlwaysSometimesRarely

Stress & Mental Wellness

Rate your stress level:

LowModerateHigh

How do you manage stress?

Exercise

How often do you exercise?

Never1–2 times/week3–4 times/week5+ times/week

Women's Hormone Health

Age at first menstrual cycle:

Date of last menstrual period:

Are your cycles regular?

YesNo

Current birth control or HRT:

Men's Hormone Health

Have you ever had testosterone levels checked?

YesNo

Environmental & Toxin Exposure

Do you have:

Mold exposureWater damage in homeChemical exposure at workHeavy metal exposure

Do you use:

Plastic food containersNon-stick cookwareArtificial fragrances

Functional Medicine Goals

What would success look like for you after working with Dr. Jacqueline Morgan Van Montague?

Treatment Interests — Check all that apply

Your answers will be sent directly to Dr. Jacqueline Morgan Van Montague's inbox to prepare for your consultation.