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

This form must be completed in order to meet with Trisha. After submitting your responses, you will be taken to Practice Better to schedule your first 30-minute Zoom consultation.

Name *

First

Last

Date of Birth *

Email *

Phone Number *

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? *

I'm interested in the 21-day gentle metabolic detox.
I have these symptoms, but am not interested right now.
I don't have these symptoms.

Assessing Readiness to Change

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

On a scale of 1 to 5, how willing are you to: *

	Not willing at all (1)	Somewhat less willing (2)	Willing (3)	Somewhat more willing (4)	Very willing (5)
1. Significantly modify your diet?	1. Significantly modify your diet? Not willing at all (1)	1. Significantly modify your diet? Somewhat less willing (2)	1. Significantly modify your diet? Willing (3)	1. Significantly modify your diet? Somewhat more willing (4)	1. Significantly modify your diet? Very willing (5)
2. Take several nutrition supplements each day?	2. Take several nutrition supplements each day? Not willing at all (1)	2. Take several nutrition supplements each day? Somewhat less willing (2)	2. Take several nutrition supplements each day? Willing (3)	2. Take several nutrition supplements each day? Somewhat more willing (4)	2. Take several nutrition supplements each day? Very willing (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? Not willing at all (1)	3. Keep a record of everything you eat and drink in a day? Somewhat less willing (2)	3. Keep a record of everything you eat and drink in a day? Willing (3)	3. Keep a record of everything you eat and drink in a day? Somewhat more willing (4)	3. Keep a record of everything you eat and drink in a day? Very willing (5)
4. Modify your lifestyle? (work demands, sleep habits)	4. Modify your lifestyle? (work demands, sleep habits) Not willing at all (1)	4. Modify your lifestyle? (work demands, sleep habits) Somewhat less willing (2)	4. Modify your lifestyle? (work demands, sleep habits) Willing (3)	4. Modify your lifestyle? (work demands, sleep habits) Somewhat more willing (4)	4. Modify your lifestyle? (work demands, sleep habits) Very willing (5)
5. Practice a relaxation technique?	5. Practice a relaxation technique? Not willing at all (1)	5. Practice a relaxation technique? Somewhat less willing (2)	5. Practice a relaxation technique? Willing (3)	5. Practice a relaxation technique? Somewhat more willing (4)	5. Practice a relaxation technique? Very willing (5)
6. Engage in regular exercise?	6. Engage in regular exercise? Not willing at all (1)	6. Engage in regular exercise? Somewhat less willing (2)	6. Engage in regular exercise? Willing (3)	6. Engage in regular exercise? Somewhat more willing (4)	6. Engage in regular exercise? Very willing (5)
7. Have periodic lab tests to assess your progress?	7. Have periodic lab tests to assess your progress? Not willing at all (1)	7. Have periodic lab tests to assess your progress? Somewhat less willing (2)	7. Have periodic lab tests to assess your progress? Willing (3)	7. Have periodic lab tests to assess your progress? Somewhat more willing (4)	7. Have periodic lab tests to assess your progress? Very willing (5)

After hitting submit, you will be able to schedule your Zoom consultation with Trisha. There is a $75 fee for the first 30-minute consult. *

I understand.

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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