Patient Screening Form

A therapeutic partnership is key to getting to the root cause of chronic illness.

Fill out the form below for a Zoom consultation.

PLEASE COMPLETE THIS FORM FIRST, THEN SCHEDULE YOUR 30-MINUTE CONSULT-SEE GREEN BUTTON BELOW THIS FORM

This form must be completed AND then click on the green button BELOW and SCHEDULE a 30-minute Zoom consultation on Practice Better.

Name & date of birth (DOB): *

Email *

Phone: What city/state do you call home? *

How did you hear about Trisha Howell and Smart Wellness® LLC? *

Assessing Commitment

What are the main 3 health concerns? *

What do you hope to achieve? *

Why functional medicine, why now? What have you tried that is not working for you now? *

Do you experience fatigue, brain fog, inability to lose weight and food sensitivities? If so, would you be interested in our 21-day gentle metabolic detox? Click on the green button BELOW & SCHEDULE your appointment on Practice Better.

Assessing Readiness to Change

Please rate on a scale of 1 to 5 (1 being not important at all and 5 being very important): How willing are you to:

Likert Scale *

	1	2	3	4	5
1. Significantly modify your diet?	1. Significantly modify your diet? 1	1. Significantly modify your diet? 2	1. Significantly modify your diet? 3	1. Significantly modify your diet? 4	1. Significantly modify your diet? 5
2. Take several nutrition supplements each day?	2. Take several nutrition supplements each day? 1	2. Take several nutrition supplements each day? 2	2. Take several nutrition supplements each day? 3	2. Take several nutrition supplements each day? 4	2. Take several nutrition supplements each day? 5
3. Keep a record of everything you eat and drink in a day?	3. Keep a record of everything you eat and drink in a day? 1	3. Keep a record of everything you eat and drink in a day? 2	3. Keep a record of everything you eat and drink in a day? 3	3. Keep a record of everything you eat and drink in a day? 4	3. Keep a record of everything you eat and drink in a day? 5
4. Modify your lifestyle? (work demands, sleep habits)	4. Modify your lifestyle? (work demands, sleep habits) 1	4. Modify your lifestyle? (work demands, sleep habits) 2	4. Modify your lifestyle? (work demands, sleep habits) 3	4. Modify your lifestyle? (work demands, sleep habits) 4	4. Modify your lifestyle? (work demands, sleep habits) 5
5. Practice a relaxation technique?	5. Practice a relaxation technique? 1	5. Practice a relaxation technique? 2	5. Practice a relaxation technique? 3	5. Practice a relaxation technique? 4	5. Practice a relaxation technique? 5
6. Engage in regular exercise?	6. Engage in regular exercise? 1	6. Engage in regular exercise? 2	6. Engage in regular exercise? 3	6. Engage in regular exercise? 4	6. Engage in regular exercise? 5
7. Have periodic lab tests to assess your progress?	7. Have periodic lab tests to assess your progress? 1	7. Have periodic lab tests to assess your progress? 2	7. Have periodic lab tests to assess your progress? 3	7. Have periodic lab tests to assess your progress? 4	7. Have periodic lab tests to assess your progress? 5

Phone

Next Step - Schedule Your 30-minute consultation

After you submit this form, please click the link below to schedule your call with Trisha.

This button will take you to the calendar app on the Practice Better site.

Start your healing journey

Important to note:

Trisha Howell MSH, RD, LD/N, IFMCP is not a Medical Doctor. She has her Master’s in Clinical Nutrition, a Registered Dietitian, Licensed Nutritionist and is highly specialized in Functional Medicine through a board-certified physician’s program with the Institute of Functional Medicine (IFM). She is the only board-certified functional medicine nutritionist in Jacksonville, FL and is 1 of 5 in the state of Florida.

She is 100% virtual. She is fee for service practice not insurance based but can provide a superbill that you can give to your insurance company-No guarantees as not all insurance companies recognize functional medicine visits.

VIRTUAL PRACTICE

Mailing Address:
4446-1A Hendricks Avenue
Suite 219
Jacksonville, FL 32207

Contact us

By filling out an inquiry and booking a consultation.

Office Hours

By appointment only