Membership Questionnaire Please provide the following information if interested in scheduling a free 15 minuteFunctional Medicine Zoom meeting to answer your questions regarding membership. Membership Questionnaire Name Date of Birth Mailing Address Email Phone How were you referred to this practice? Do you live in Oregon state? Yes No Do you live in Washington state? Yes No Do you have a Primary Care Provider? Yes No If yes, who is your Primary Care Provider? Have you seen any medical specialists in the past two years? Yes No If yes, please list the specialists you have seen recently: Are you currently taking any prescription medications? Yes No If yes, please list the medications you are currently taking: Do you have medical insurance? Yes No If insured, what is the name of your insurance company and plan? Please list your main health concerns: Submit Δ
