Functional Medicine Intake Form

Functional Medicine — New Patient Intake

At Kōena, functional medicine means finding the root cause — not just treating symptoms. This is very detailed. Please give yourself some time to sit and fill this out. Please answer the questions as honestly as possible. No judgment. This is a very safe space. The more detail you give, the better prepared we will be for your visit. All information is confidential.

First name

Last name

Are you currently a patient at Koena?

Yes

Phone

Birthday

Month

Day

Year

Address

Current diagnosed conditions?

Past significant illnesses or hospitalizations:

Current meds and supplements

Any allergies? Drug, environmental, food etc

Have you had any blood work done in the past 12 months?

Yes

Do you smoke?

yes

sometimes

I quit

Do you drink alcohol?

yes

occasionally

yes, more than I should

In your own words, what is your main health concern?

How long has this been going on?

Have you seen other providers for this? if so, what were you told?

What have you tried in the past?

What does feeling better look like to you?

When is the last time you felt great?

Tell me about your job? Do you fill fulfilled?

Any significant toxic exposures — mold, chemicals, pesticides?

yes

unsure

Do you have any metal in your mouth or body?

yes, dental fillings

yes, surgical hardware

unsure

Tell me about your sleep patterns? Do you wake in the middle of the night?

Tell me about your diet. No judgement here. Just gathering info.

How often do you exercise? What types of exercise do you do?

Trauma & Stress History

We understand these questions are personal. You only need to share what you're comfortable with. Trauma — physical, emotional, or psychological — has a profound impact on physical health and is an important part of understanding the whole picture.

Tell me about your stress level? What are your main sources of stress?

How would you describe your current mental well being?

I feel pretty good most of the time

I do ok, I'm managing

I mostly struggle but I'm making it

I struggle significantly with mental health

Are you currently seeing a mental health provider?

Yes

No but I am interested

Tell me what brings you joy?

Is there anything about your stress or trauma history you'd like us to know before your appointment

Is there anything from above that you need to explain and / or clarify?

Is there anything else you would like your providers to know?

INFORMED CONSENT FOR FUNCTIONAL MEDICINE CONSULTATION

Kōena Integrative Medicine

Functional medicine services at Kōena are provided by Dr. Lyndsey

Cordova, DAC, LAc, or Courtney Williams, FNP. Any prescribed medications will be under the clinical supervision and approval of Medical Director Courtney Williams, NP.

By submitting this form I acknowledge and agree to the following:

1. NATURE OF SERVICES: Functional medicine focuses on

identifying root causes of illness through comprehensive health

history, lifestyle assessment, and laboratory testing. It is

not a replacement for emergency medical care.

2. COLLABORATIVE CARE: My care may involve collaboration

between Dr. Lyndsey Cordova and Medical Director Courtney Williams or Caroline Arnette, LAc.

I consent to my health information being shared among my Kōena

care team for the purpose of coordinating my care.

3. LAB WORK: Additional lab work may be recommended. I will

be informed of associated costs before proceeding.

4. EMERGENCY CARE: Kōena is not an emergency service. If I

am experiencing a medical emergency I will call 911 or go to

my nearest emergency room immediately.

5. ACCURACY: All information on this form is accurate and

complete to the best of my knowledge. I understand that

withholding medical history may affect the quality and safety

of my care.

6. HIPAA: My health information is protected under HIPAA and

will only be shared with my Kōena care team or as required

by law.

7. COMMUNICATION: I consent to being contacted by Kōena

Integrative Medicine via phone, email, or text regarding

my care.

By typing my full name below I am providing my electronic

signature and confirming my agreement to the above.

Signature

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