Initial Screening

Welcome.

If you have been referred here by one of my colleagues, please complete the following form in order to ensure you qualify as a patient for nutritional/functional medicine.

If you haven’t already, please read carefully the Process and Fees pages.

And as a reminder:

Who I don't work with

I look forward to hearing from you.

Full Name:

DOB:

Email address:

Referred by:
(Write N/A if not referred)

What is your primary health concern you wish to work on?
(Briefly list symptoms and previous diagnosis).

Any other secondary issues you wish to address?
(Briefly list symptoms and previous diagnosis).

What would you consider a positive outcome from treatment for the issues above?

Are you able and willing to invest financially in diagnostic lab tests to help diagnose the root causes of your current health concerns?
(Testing recommendations are personalised but an initial investment would typically be £250-350 up to £1,000. These are not necessarily mandatory and the costs with benefits are always discussed before a plan is agreed).

On a scale of 1-10 (1 unwilling, 10 very willing), how willing are you (with help and support) to change you diet by removing certain food groups, some in the short term weeks/months and others in the longer term (years/forever)?

On a scale of 1-10 (1 unwilling, 10 very willing) and in addition to any recommended dietary changes, how willing are you to take supplements on a daily basis?

On a scale of 1-10 (1 unwilling, 10 very willing), how willing are you (with help and support) to engage in some form of relaxation/meditation/mindfulness on a daily basis?

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