Health Intake Questionnaire — Root Restore Health

About You

Basic information so we can prepare for your consultation.

Full name Date of birth Email Phone City, state / country Occupation

Your Health Story

Tell us what brings you here and what you've already tried.

What are your top 3 health concerns, in order of importance? When did these begin, and what was happening in your life at that time? What makes your symptoms better or worse? Diagnoses you have received (past or present) Surgeries, hospitalizations, or major injuries Current medications (name & dose) Current supplements (name & dose) Allergies or intolerances (medications, foods, environmental) Significant family health history (parents, siblings, grandparents)

Symptom Review

The next five sections use a standard functional medicine rating scale. For each symptom, rate how it has affected you over the past 30 days.

0 — Never or almost never · 1 — Occasionally, mild · 2 — Occasionally, severe · 3 — Frequently, mild · 4 — Frequently, severe

Lifestyle & Daily Rhythms

Sleep, nutrition, movement, and stress are foundations of root-cause health.

Average hours of sleep per night Sleep quality Current stress level (0 = none, 10 = extreme) Exercise per week Caffeine per day Alcohol per week Tobacco or nicotine use Water intake per day

Describe a typical day of eating (breakfast, lunch, dinner, snacks) What do you do to manage stress or restore yourself?

Goals & Readiness

If we worked together and it was successful, what would be different in your life 6 months from now? On a scale of 1–10, how ready are you to make changes to your nutrition and lifestyle? Anything else you'd like us to know?

Your Symptom Summary

Scores update automatically as you answer. Higher section scores help highlight areas to explore during your consultation.

Total symptom burden0

General guide: under 10 — optimal · 10–50 — mild symptom burden · 50–100 — moderate · over 100 — significant. This is a wellness screening tool, not a medical diagnosis.

Submit Your Questionnaire

Choose Print / Save as PDF to create a complete copy of your answers, then email it to stan@rootrestorehealth.com or upload it when booking. You can also send just your scores now.

Root Restore Health provides wellness consulting and does not diagnose or treat medical conditions. Your information is kept confidential and used only to prepare for your consultation.