Functional Medicine Questionaire

Have you worked with Momentum Medical before?

No, this is my first time exploring your services. No, I’ve inquired before but didn’t move forward. Yes, I’ve worked with you before but need additional support.

What’s your first name?

What’s your last name?

Phone Number

Please provide a mobile phone number in case we need to reach out for clarification.

By providing your number, you agree to receive text messages from us regarding your application.

What is your marital status? (Required)

I am married. I have a partner. I am single.

Are you experiencing chronic pain, inflammation, hormone imbalance, and/or gut issues?

Yes No I’m not sure

What is your #1 challenge with getting healthier?

What areas do you need the most help with?

Getting to the root cause of my health issues Understanding my lab results / Communicating with doctors Creating a sustainable, healthy diet / Finding the right supplements Managing chronic pain Reducing inflammation Balancing my hormones Improving gut health / Digestion All of the above

What health solutions have you tried that didn’t work?

How are your health issues impacting your daily life?

Why not continue with your current approach to solving your health issues?

How confident are you in your current health plan?

Very confident – I don’t really need help, just curious. Somewhat confident – I need help figuring out what’s missing. Not confident at all – I need guidance on where to start.

How much are you willing to invest in a solution that truly works for you?

I don’t have the finances right now, but I may in the future. $200 – $1K – About the cost of a nice TV or furniture. $1K – $3K – Comparable to a vacation. $3K – $5K – Similar to a home renovation project. I’m ready to invest whatever it takes as long as it works for me.

Why do you believe you’d be a good fit for our program?

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Foundations of Health: Functional Medicine Self-Assessment

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